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FOOD,  HEALTH  AND  GROWTH 


THE    MACMILLAN    COMPANY 
tarvr  yokt  •  boston  •  Chicago  •  "ah  aj 

ATLANTA    •    SAN  FRANCISCO 

MACMILLAN  ft  CO.,  Lmmm 

LONDON    •    BOIiBAT    •    CAL£UTTA 
IfKLBOURNX 

THB  lilACMILLAN  CO.  OP  CANADA.  Li& 

XOKOMTO 


Food,   Health  and  Growth 

A  Discussion  of  the  Nutrition  of  Children 


BY 

L.  EMMETT  HOLT,  M.D.,  LL.D. 

Author  of  "The  Care  and  Feeding  o]  Children,"    "The    Diteasei    of   Infancy 
and  Childhood" 

PRESIDENT     CHILD     HEALTH     ORGANISATION  ;     FORMEELY     PEO- 

PESSOB  OF  DISEASES   OF  CHILDREN    IN   THE   COLLEGB 

or  PHYSICIANS  AND  SURGEONS,  CX>LUMBLA. 

UNIVEBSITY,     NEW     YOBK 


BEALTE  IV  EDUCATION    ^      \      I    ^    EDUCATION  IN  EKALTB 


THE  MACMILLAN  COMPANY 
1923 


AU  righti  r«»ert«d 


PRINTED  IN  THK  UNITED  STATES   Or  AMERICA 


ooptrioht,  1922, 
bt  the  MACMILLAN  COMPANT. 


8«t  up  and  electrotypsd.     Published  June,  1922. 


Press  of 

J.  J.  Little  k  Ives  Company 

New  York,  U.  S.  A. 


Dedicated  to 
BAY  LYMAN  WILBUR,  M.D.,  LL.D. 

PBESIDEN'T   LELAND   STANPOBI 
JUNIOE   UNIVERSITY 

PHYSICIAN,    EDUCATOE    AND 
ADMINISTEATOB 


\\ 


PREFACE 

This  little  volume  contains  the  Lane  Lec- 
tures given  at  the  Medical  School  of  the  Le- 
land  Stanford  Junior  University  in  San 
Francisco  in  December,  1921.  The  lectures 
are  published  substantially  as  they  were  de- 
livered. 

The  book  is  not  therefore  to  be  regarded 
as  a  text-book  or  even  a  systematic  discussion 
of  the  aspects  of  nutrition  which  are  here 
considered.  But  out  of  the  wide  range  of 
topics  relating  to  the  nutrition  of  children 
certain  ones  have  been  chosen  which  seemed 
of  special  interest  and  importance  at  the  pres- 
ent time,  even  though  they  are  apparently 
not  closely  connected. 

Everything  relating  to  the  subject  of  nutri- 
tion and  especially  the  food  and  nutrition  of 
children  has  acquired  a  new  interest  in  the 
last  few  years  and  much  new  knowledge  has 
been  added.  The  effort  has  boon  made  in 
these  lectures  to  present  some  of  this  in  such 
a  simple  form  as  to  make  it  available  to  the 
student  of  nutrition  and  the  general  reader. 


viii  PREFACE 

It  has  not  been  thought  desirable  to  burden 
the  text  with  references  to  the  XJublications  of 
the  authors  whose  work  is  mentioned  in  these 
lectures.  I  must,  however,  express  my  spe- 
cial indebtedness  to  the  Report  of  the  British 
Mediciil  Eesearch  Committee  upon  Acces- 
sor}' Food  Factors  (Vitamines). 

The  second  and  third  lectures  are  based 
upon  studies  which  have  been  carried  on, 
chiefly  at  the  Babies'  Hospital  during  the  past 
three  years,  jointly  by  the  author  and  Helen 
L.  Fales  to  whom  acknowledgment  is  made 
for  cooperation  and  assistance.  The  chemical 
work  in  connection  with  this  study  was  done 
by  Miss  P^ales,  to  whom  I  am  also  indebted 
for  the  tables  of  caloric  food  values  in  the 
Appendix. 


CONTENTS 


LECTUKI  rASl 

I.    Nutrition     in     Eelation     to    Growth,    to 
Mental    Progress    and   to    Resistance    Ta  " 
Disease  1 

II.    The  Food  Requirements  or  Children  During 

THE   Entire   Period   of   Growth    .     .     .     .    '    47 

III,  The  Conditions  Upon  Which  Are  Based  the 
Requirements  for  Protein,  Fat,  Carbohy- 
drate AND  Mineral  Salts.  The  Percent- 
age OF  THE  Different  Food  Constituents  in 

THE  Diet  of  Children 87 

IV.  Vitaminis 149 

V.    Practical   Means  by  Which  the  Nutrition 

of  Children  May  Be  Improved 208 

VI.    Appendix 263 

Index 269 


ILLUSTRATIONS 

nocBB  piai 

1.  Nutrition  and  School  Progress,  Washington,  D.  C.  26 

2.  Weight  and  School  Progress,  Detroit  Boys    .      .  28 

3.  Annual   Gain   in   Weight    and   Height   for   Both 

Seies        53 

4.  Calories  per  Kilo,  for  Boys     ......  68 

5.  "          "       "       "     Girls      .      .      .     ..,     .     ..  68 

6.  Total  Daily  Calories  for  Boys 74 

7.  "         "           "         "    Girls 74 

8.  "         "           "         100  Individual  Observations  81 

9.  Proteins  Reinforced  by  Addition  of  Amino-Acids  93 
iQ              <(                   <(               <<           n           <(          <<           ti  g2 

11.  Grams  Total  Protein  Taken  Daily 101 

12.  Percentage  of  Animal  and  Vegetable  Proteins   .  104 

13.  Percentage  Distribution  of  Total  Carbohydrate  .  127 

14.  Growth  with  Diets  Deficient  in  Mineral  Salts    .  136 

15.  Distribution  of  Calories  Taken  by  Healthy  Chil 

dren 


16.  Distribution  Total  Calories — Boys 

17.  •'  "  "       —Girls      .      . 

18.  '*  "  "Per  Kilo— Boys 

19.  "  "  "        "       "   —Girls 


20.     Effect  of  Addition  of  Milk  to  Purified  Foodstuffs     153 


21.  Growth  on  Diets  Deficient  in  Vitaininps    . 

22.  Deficiency  of  Vitamine  "A"  in  Vopetable  Oils 

23.  Growth    with    Vitamine     "B"     from     Different 

Plants 

24.  Amounts  of  Foods  Needed  to  Prevent  Scurvy 


140 
143 
143 
144 
144 


156 
160 

170 
182 


FOOD,  HEALTH  AND  GROWTH 


Food,   Health   and  Growth 


CHAPTER  I 

Lecture  One 


Nutrition  in  Its  Belation  to  Growth,  to  Progress 
in  School  and  to  B«sistance  to  Disease. 


The  problem  of  nutrition  is  older  than  the 
human  race.  It  began  when  life  began  upon 
this  planet.  The  survival  of  a  species  of 
plants  and  later  of  animals  was  conditioned 
upon  their  finding  proper  food  and  a  favour- 
able environment. 

Not  only  the  physical  development  of 
man  but  the  fate  of  nations  has  been  in  the 
past  in  no  small  degree  dependent  upon 
their  ability  to  solve  the  food  question. 
This  is  true  in  peace  times ;  but  in  war  time 
the  problem  of  feeding  an  army  or  navy  is 
quite  as  important  as  munitions.  It  was 
American  wheat  quite  as  much  as  American 
men  which  determined  the  outcome  of  the  last 
war. 

1 


2  FOOD,    HEALTH   AND   GROWTH 

Early  in  1918  Lord  Rhondda,  the  Brit- 
ish Food  Controller,  is  reported  to  have  said 
to  the  War  Council:  "Gentlemen,  we  are 
through.  The  Allies  have  lost  the  war.  We 
are  reaching  the  end  of  our  food  supply." 
He  cabled  to  Mr.  Hoover  that  unless  the 
United  States  could  send  an  extra  allowance 
of  seventy-five  million  bushels  of  wheat  the 
Allies  could  not  hold  out  until  the  American 
troops  should  arrive. 

In  many  revolutions  the  food  question  has 
been  the  potent  factor  in  stirring  people  to 
overthrow  their  government. 

As  never  before  in  modern  times  the  sub- 
ject of  food  and  nutrition  has  come  to  the 
front  today.  It  is  probably  the  most  pressing 
world  problem.  It  was  beginning  to  be  felt 
even  before  the  war;  but  greatly  decreased 
production  and  consequent  high  cost  of  food 
have  intensified  conditions  and  made  the 
situation  more  acute.  We  have  often  seen  the 
results  of  prolonged  underfeeding  of  indi- 
viduals. We  are  now  witnessing  the  conse- 
quences of  the  underfeeding  of  whole  nations. 
The  glimpses  which  we  are  able  to  obtain 
from  reports  of  conditions  in  Poland  and 
China  and,  most  of  all,  in  Russia  help  us  to 
realise  this  to  a  small  degree. 

All  unfavourable  hygienic  conditions,  lack 


SUSCEPTIBILITY   OP    CHILDREN  3 

of  proper  food  particularly,  bear  most  heav- 
ily upon  children.  They  have  less  resistance 
than  adults.  They  are  more  susceptible  to 
infection,  and  the  consequences  of  prolonged 
underfeeding  are  much  more  serious.  With 
adults,  underfeeding  if  not  extreme  in  degree, 
even  though  prolonged,  may  greatly  reduce 
efl&ciency  without  seriously  or  permanently 
impairing  health.  Not  so  with  children.  With  (jwidren 
them  the  food  allowance  must  be  not  only  ^li£,^' 
sufficient  for  energy  and  the  repair  of  waste,  *^°"* 
but  in  addition  a  large  allowance  must  be 
supplied  for  growth.  Furthermore,  there  are 
certain  food  constituents  essential  for  growth, 
and  unless  these  are  furnished  in  the  food 
growth  suffers  even  though  the  quantity  of 
food  is  sufficient. 

The  health,  growth  and  physical  develop- 
ment of  children  and  to  a  considerable  degree 
their  mental  development  and  progress  de- 
pend upon  their  nutrition. 

It  is  for  these  reasons  that  I  have  chosen 
the  nutrition  of  children,  especially  the  food, 
health  and  growth  of  children,  as  the  general 
topic  of  these  lectures. 

The  subject  is  a  very  broad  one;  all  that 
will  be  attempted  will  be  to  point  out  some 
of  the  most  important  bearings  of  nutrition 
upon  the  life  of  the  children,  to  bring  to  your 


4  FOOD,   HEALTH   AND   GROWTH 

notice  some  of  the  results  of  the  more  recent 
laboratory  studies  which  have  shed  new  light 
upon  this  subject  and  finally  to  discuss  the 
question  of  how  malnutrition  in  children,  as 
it  exists  in  this  country  today,  may  be  solved. 
\      We  are  continually  reminded  of  the  fact 
that  in  business  there  are  too  many  middle- 
men, and  that  the  public  interest  suffers  in 
1  consequence.    But  is  it  not  true  that  in  science 
^  we  have  too  few  ?    There  is,  I  believe,  at  the 
Middlemen    prescut  time,  a  need  of  one  who  shall  stand 
Science        bctwcen  the  producer,  that  is  the  research 
worker  in  the  laboratory,  and  the  ultimate 
consumer,  who  may  be  the  practising  physi- 
cian, the  health  worker  or  the  general  public. 
Such  a  middleman  I  shall  hope  in  these  lec- 
tures to  be. 

Health  and  normal  nutrition  are  not  quite 
synonymous  terms ;  yet  as  applied  to  children 
during  the  period  of  growth  they  are  so 
closely  allied  that  one  may  be  taken  as  an  in- 
dex of  the  other.  While  there  may  be  normal 
nutrition  without  health,  there  cannot  be 
health  without  normal  nutrition. 

Nutrition  in  infancy  has  been  given  a  great 
deal  of  careful  study  for  the  last  thirty  years. 
So  successful  has  been  the  campaign  both  in 
this  country  and  in  Europe  which  has  been 
waged  against  a  high  infant  mortality,  that 


BEDUCTION  OP  INFANT  DEATH  RATE     O 

some  of  the  results  seem  little  short  of  mar- 
velous. In  New  York  City,  for  instance,  the 
infant  death  rate  has  been  reduced  during 
this  period  practically  to  one-third  the  figure 
of  a  generation  ago.  The  average  for  the 
last  four  years  is  86  per  1000;  formerly,  in 
1880,  it  was  280  per  1000.  This  has  been 
brought  about  by  the  cooperation  of  many 
agencies;  among  which  we  may  mention  the 
pasteurisation  or  sterilisation  of  milk ;  closer 
supervision  and  new  standards  for  the  pro- 
duction and  handling  of  the  milk  supply; 
cleaner  streets ;  supervision  of  infants  in  milk 
stations  and  in  their  homes  by  visiting  nurses ; 
a  better  understanding  of  the  problems  of  in- 
fant feeding  and  hygiene  both  by  the  profes- 
sion and  the  laity;  more  rational  and  more 
intelUgent  treatment  of  infants  acutely  ill, 
and  many  others.  Not  much  of  this  has  been 
accomplished  by  legislative  means ;  most  of  it 
is  the  result  of  educational  measures.    These 

1  111-  •       i-  ^      (}     Educational 

have  taken  time,  organisation,  money  and  oi-  Measures 
fort.    Not  only  the  ignorant  mother  had  to  be  important 
educated,  but  nurses,  health  officers  and  most 
difficult  at  times  of  all,  the  practising  phy- 
sician. 

Success  or  failure  in  nutrition  in  infancy  is 
soon  evident  even  to  the  most  unintelligent. 
It  is  not  difficult  to  see  whether  a  baby  is 


6  FOOD,   HEALTH  AND   GROWTH 

thriving  or  not  thriving.  Death  follows  so 
regulariy  and  often  so  soon  upon  failing  nu- 
trition that  even  those  least  enlightened  can 
hardly  fail  to  connect  cause  and  effect. 

Strangely  enough,  after  this  perilous  pe- 
riod of  the  first  two  years  of  life  was  passed, 
vigilance  as  to  health  and  nutrition  almost 
ceased;  very  little  attention  has  been  given 
until  the  most  recent  years  to  these  subjects 
during  the  remainder  of  the  growth  period. 
Not  until  a  child  entered  school  did  he  come 
under  any  kind  of  public  supei'vision.  Some- 
thing was  done  then  through  the  medical  ex- 
amination of  school  children,  but  this  has  in 
most  instances  had  for  its  object  the  exclusion 
of  cases  of  contagious  disease  or  the  detection 
of  defects  of  vision  or  hearing,  or  the  pres- 
ence of  large  tonsils  and  adenoids  or  carious 
teeth.  Observations  upon  the  nutrition  of 
school  children  have  been  until  the  last  two 
or  three  years  entirely  omitted  and  the  whole 
question  ignored. 

The  child  of  pre-school  age  has  received 
even  less  attention  than  the  school  child — in 
most  communities  none  at  all  except  when 
acutely  ill. 

One  reason  for  the  neglect  of  the  child's 
nutrition  after  infancy  has  been  that  the  ef- 
fects of  failure  are  not  evident  at  once,  and 


DRAFT  REVELATIONS  Y 

may  not  be  for  years.  Although  these  chil- 
dren seldom  die  as  a  result  of  such  failure 
they  may  be  stunted  in  growth,  under  weight, 
anaemic,  with  feeble  resistance  to  disease  and 
altogether  lacking  in  the  physical  energy 
which  we  call  ''animal  spirits,"  which  make 
study,  work  and  play  a  joy  to  the  healthy  hu- 
man animal. 

The  first  real  awakening  to  actual  condi- 
tions as  to  the  health  and  nutrition  of  the  ris- 
ing generation  and  their  consequences  was 
the  result  of  the  selective  draft,  in  which, 
though  exact  figures  vary  in  different  states 
and  communities,  somewhere  in  the  neigh- 
bourhood of  30  per  cent  of  our  young  men  ^*^^^' 
were  rejected  as  physically  unfit  for  service,  ^"y^ry 
This  was  really  the  first  general  health  inven- 
tory which  had  ever  been  taken  in  this  coun- 
try. That  similar  results  would  have  been 
found  had  an  equal  number  of  young  women 
been  subjected  to  a  critical  examination,  can 
only  be  surmised.  In  the  opinion  of  many 
even  a  worse  showing  would  have  been  made. 

Since  that  time  a  number  of  extensive  sur- 
veys have  been  made  upon  the  health  and  nu- 
trition of  school  children.  These  have  yielded 
results  which  correspond  very  closely  \Wth 
those  obtained  by  the  draft.  The  propor- 
tion of  under-weight  children  and  those  suf- 


8  FOOD,    HEALTH   AND   GROWTH 

f ering  from  defects  which  affect  nutrition  and 
hamper  growth  has  been  found  to  be  amaz- 
ingly large,  in  most  communities  fully  30 
per  cent. 

The  conditions  mentioned  are  by  no  means 
confined  to  our  large  cities;  those  found  in 
rural  communities  have  been  quite  as  bad, 
often  worse.  Nor  are  they  seen  only  among 
the  poor.  Ignorance,  indifference  and  neglect 
are  far  more  important  causes  than  poverty. 

It  is  admitted  by  all  thoughtful  persons 
that  the  greatest  of  all  the  resources  of  a  na- 
tion are  its  children,  but  without  any  question 
it  is  the  one  which  has  been  most  neglected. 
Where  does  the  blame  rest  that  we  are  allow- 
ing from  six  to  eight  millions  of  children  in 
this  country  to  grow  to  manhood  and  woman- 
hood A\ith  a  physical  development  which  ren- 
ders them  quite  unequal  to  meet  the  demands 
of  modern  life? 

My  oAVTi  opinion  is  that  the  responsibility 

■ponsibu-   for  the  neglect  of  the  nutrition  of  children 

Negiecud"^     can  bo  laid  partly  upon  the  home,  partly  upon 

the  state  and  certainly  a  share  of  it  must  be 

laid  at  the  door  of  the  medical  profession. 

The  failure  of  the  home  may  be  ascribed 
to  several  causes,  probably  the  most  impor- 
tant of  which  is  the  ignorance  of  parents 
themselves  regarding  often  the  simplest  prin- 


CbUdren 


FAILURE  OF  THE  HOME  3 

ciples  of  nutrition.  We  know  about  any  sub- 
ject only  what  we  have  been  taught  either  by 
our  o^vn  experience  or  that  of  others.  Some 
of  this  knowledge  which  relates  to  food  and 
health  is  family  tradition;  some  of  it  repre- 
sents racial  custom.  Much  of  it  is  the  result 
of  prejudice  or  even  superstition  and  rests 
upon  ideas  long  proven  by  modern  science  to 
be  erroneous. 

In  most  homes  a  growing  child  is  simply 
a  member  of  the  household.  After  the  first 
two  or  three  years  he  gets  the  same  food  as 
the  adult  members  of  the  family.  That  there 
are  certain  needs  of  the  body  for  normal 
growth  which  must  be  supplied  in  the  diet 
of  children,  and  which  adults  do  not  require, 
is  something  which  most  mothers  have  never 
heard. 

That  the  failure  of  a  boy  or  girl  to  grow 
properly  was  in  any  way  to  be  connected 
with  the  food  given,  if  only  it  was  abundant 
in  amount,  would  seem  to  most  parents 
absurd. 

Again,  the  weak  indulgence  of  their  chil- 
dren by  many  parents  permits  the  formation 
of  tastes  and  habits  in  the  selection  of  their 
food,  in  the  manner  of  eating,  and  their  mode 
of  life  generally,  which  are  quite  incompat- 
ible with  normal  nutrition  and  growth.    This 


10  FOOD,   HEALTH   AND   GROWTH 

is  a  cause  which  will  always  be  most  difficult 
to  remove. 

Economic  conditions — poverty,  intemper- 
ance, vice  and  general  shiftlessness — are 
causes  which  will  always  exist  as  a  basis  for 
an  irreducible  minimum  number  of  malnour- 
ished children.  If  most  parents  fail  because 
of  lack  of  knowledge  who  is  responsible  for 
teaching  them?  They  will  certainly  go  on 
repeating  indefinitely  the  mistakes  of  their 
parents,  unless  some  intelligent  outside  help 
is  given.  The  public  press  has  done  a  good 
deal  in  recent  years,  especially  since  the  be- 
ginning of  the  Great  War.  Mothers  have 
been  taught  something  in  clubs;  something 
by  visiting  nurses  in  the  homes  and  in  clinics 
or  hospitals;  something  by  health  literature 
distributed  by  private  organisations,  or  pub- 
lic health  agencies.  In  schools,  older  girls 
have  been  taught  something  about  foods  and 
cooking.  But  what  has  been  done  so  far  has 
barely  scratched  the  surface.  That  so  little 
has  been  accomplished,  the  medical  profes- 
sion, I  believe,  is  in  no  small  degree  to  be 
blamed.  For  it  is  they  who  should  be  the 
teachers  and  the  leaders  in  forming  a  public 
opinion  w^hich  is  absolutely  necessary  if  tlie 
present  conditions  are  to  be  materially  im- 
proved. 


THE  physician's  RBSPONSIBILITT  11 

But  one  sometimes  hears  the  remark  made 
— *  *  doctors  don 't  know  anything  about  health ; 
all  their  time  and  energies  are  devoted  to  a 
study  of  disease ;  their  interest  is  in  disease, 
not  in  health."     The  medical  schools  have 
taught  little  or  nothing  about  health,  only 
about  disease.    That  a  knowledge  of  normal 
nutrition,  which  is  the  very  basis  of  health,  Th« 
is  an  essential  part  of  a  physician's  educa-  fJoSd^e 
tion  is  a  very  recent  conception.     That  his  Teacher 
highest  duty  to  his  patients  is  to  teach  them 
the  rules  of  health  and  how  to  obey  them,  is 
something    very    few    physicians    probably 
would  admit.    But  is  it  not  true  as  regards 
the  children  under  his  care? 

In  the  past,  the  physician  was  consulted 
only  in  case  of  illness  or  accident;  no  one 
ever  thought  of  seeking  his  advice  at  any 
other  time.  The  phj^sician's  function  was  to 
relieve  people  of  their  aches  and  pains  and 
help  them  on  their  feet.  His  office  was  the 
repair  shop.  If  a  mother  felt  the  need  of 
some  advice  regarding  the  diet  of  her  chil- 
dren she  asked  her  mother,  some  friend,  or 
possibly  a  nurse,  but  seldom  her  physician. 
The  chief  reason  why  his  advice  was  not 
sought  in  matters  of  diet  and  general  hygiene 
was  because  it  was  discovered  that  about 
these  things  he  knew  very  little  more  than 


12  POOD,   HEALTH  AND  GROWTH 

other  people.  The  cause  of  this  was  in  large 
measure  due  to  a  failure  of  the  medical  school 
where  he  was  educated  to  take  any  account  of 
these  subjects,  or  it  looked  upon  them  as 
quite  unimportant. 

But  a  decided  change  is  gradually  coming 
about.  In  the  last  few  years  there  is  one 
phase  of  nutrition  which  in  most  communities 
has  come  to  be  recognised  as  a  physician's 
field,  viz.,  infant  feeding  and  hygiene. 

That  there  was  more  knowledge  on  these 
matters  than  was  the  possession  of  grand- 
mothers and  gray-haired  nurses,  a  large  pro- 
portion of  the  young  mothers  of  the  present 
generation  have  come  to  appreciate,  and  an 
improved  crop  of  babies  and  a  great  reduc- 
tion in  the  amount  of  sickness  and  death  of 
infants  has  been  the  result. 

The  possibilities  in  the  prevention  of  dis- 
ease, not  only  in  infancy  but  during  the  en- 
tire period  of  childhood  and  indeed  through- 
out life,  are  just  beginning  to  dawn  even 
upon  the  medical  profession.  There  still  ex- 
ists, I  regret  to  say,  a  large  number  of  phy- 
sicians who  look  upon  these  modern  move- 
ments in  preventive  medicine  as  something 
Opposition  ^^  -^^  deprecated,  which  is  interfering,  and 
they  consider  very  improperly  too,  with  their 
legitimate  business.    There  is  at  present  an 


Tentive 
Mwlicin* 


THE  physician's  DUTY  13 

organised  body  of  physicians  in  New  York 
City — I  am  glad  to  say  not  a  very  large  or 
influential  one — who  systematically  oppose 
public  health  measures  upon  this  ground. 
Such  a  feeling  is  perhaps  not  unnatural,  but 
cannot  outlast  the  present  generation  of  phy- 
sicians who,  trained  in  the  school  of  old  tra- 
ditions, find  it  hard  to  adapt  themselves  to  a 
changed  order  of  things. 

That  one  of  the  most  important  functions 
of  the  physician  is  that  of  a  health  teacher, 
and  also  that  one  of  the  most  important 
branches  of  education  is  health  education,  are 
two  ideas  which  are  rapidly  coming  to  be  ac- 
cepted by  the  most  intelligent  and  forward- 
looking  persons,  but  have  not  yet  touched  the 
majority  of  physicians  or  school  superin- 
tendents and  teachers. 

If  there  is  any  period  of  life  when  the  ap- 
plication of  science  to  health  should  show 
results,  it  is  during  the  period  of  growth.  A 
knowledge  of  the  physiological  and  biological 
principles  upon  which  normal  nutrition  rests  chudhood. 
must  be  given  to  the  medical  student.  The  tuW 
application  of  this  knowledge  in  the  super- 
vision and  direction  which  it  enables  the  phy- 
sician to  give  to  those  who  have  the  respon- 
sibility for  the  physical  welfare  of  children, 
should  be  regarded  as  not  only  one  of  his 


14 


POOD,  HEALTH  AND  GROWTH 


The  Duty 
of  tha 
StaU 


The  OoT- 

•mmant 
Spend! 
liberally 
for  Anlm&Ii 


chief  duties,  but  as  one  of  his  greatest  oppor- 
tunities. It  is  certainly  the  opportunity  of 
the  young  physician. 

Has  the  Federal  or  State  Government  any 
share  of  the  responsibility  for  the  health  and 
nutrition  of  children!  If  the  home  has  ut- 
terly failed  and  if  the  medical  profession  has 
not  met  the  situation,  it  surely  becomes  the 
duty  of  the  State  to  take  a  hand.  How  far 
shall  the  State  go!  Shall  it  be  content  sim- 
ply with  efforts  at  enlightenment  of  the  pub- 
lic, or  shall  it  go  further  and  exercise  some 
sort  of  supervision,  through  the  schools  or 
the  health  authorities,  of  the  physical  de- 
velopment of  children?  These  are  questions 
which  the  future  must  decide. 

It  has  long  been  recognised  as  one  of  the 
legitimate  functions  of  government  to  estab- 
lish and  maintain  experiment  stations  where 
methods  of  raising  pigs,  calves  and  poultry 
in  the  best  and  most  economical  way  are 
studied  and  determined  by  experts.  The 
Federal  Govenmient  spent  last  year  $9,700,- 
576  in  appropriations  for  the  Department  of 
Animal  Industry.  This  department  has 
4045  employees.  The  appropriation  is  nine 
times  as  large  as  it  was  twenty  years  ago. 
Besides  this,  many  states  maintain  separate 
experiment   stations   which   are  working  at 


EXPENDITURES  FOR  HEALTH  16 

these  same  problems.  All  this  expert  knowl- 
edge is,  through  the  bulletins  issued,  at  the 
service  of  the  smallest  farmer  in  the  most  re- 
mote country  district. 

What  is  the  Government  doing  for  the 
nutrition  of  the  children!  The  Children's 
Bureau  which  was  established  in  1912  has  a 
staff  of  about  one  hundred  and  the  appropria-  }J^g®*J„ 
tion  for  1921  was  $271,000.  The  Public  Health  cmi<^ 
Service  is  principally  concerned  with  epi- 
demic diseases,  quarantine  conditions  and 
other  problems  in  which  the  relation  of  health 
to  commerce  is  especially  close.  Its  appro- 
priation for  the  health  of  children  last  year 
was  $40,000,  most  of  which  was  expended  in 
making  surveys. 

In  addition  to  what  is  spent  by  the  Federal 
Government  for  health  there  must  of  course 
be  added  the  amount  appropriated  by  local 
authorities.  The  average  annual  appropria- 
tion for  all  health  purposes  of  cities  of  dif-  spend  for 
ferent  classes  in  the  United  States  is  as  fol- 
lows: 

12  cities  with  population  of  ovrr  500,000 $1.06  per  capita 

12  "       "            "  250,000  to  f>oo,nno 1.04  "        " 

68  "         "              "  less  than  250,000 72  "          " 

24  "         "              "  from  12,000  to  45,000 70  " 

For  most  of  these  figures  I  am  indebted  to 
the  Committee  of  the  American  Public 
Health  Association. 


Health 


16  POOD,    HEALTH  AND   GROWTH 

There  are  good-sized  towns  in  the  East  and 
in  the  Middle  West  whose  total  expenditure 
for  health  is  less  than  fifteen  cents  per  capita ; 
less  than  the  average  single  admission  to  a 
moving  picture  show. 

Of  course  only  a  small  part  of  this  appro- 
priation has  to  do  with  the  health  of  children. 
New  York,  which  is  more  liberal  than  most 
cities,  spends  about  one-sixth  of  its  total 
health  appropriation  for  children,  or  seven- 
teen cents  per  capita. 

If  we  estimate  the  worth  of  anything  by 
what  we  are  willing  to  spend  for  it,  the  value 
set  upon  health  and  especially  the  health  of 
children  in  this  country  is  not  a  very  high 
one. 

While  much  has  been  done  and  is  still  be- 
ing done  by  private  agencies  to  promote  edu- 
cation in  matters  of  health,  we  conceive  it  to 
be  the  duty  of  the  State  to  make  available 
for  its  humblest  citizen  the  ver\^  best  which 
modern  science  has  discovered  ^rith  respect 
to  the  nutrition  of  children. 

We  insist  in  this  country  upon  compulsory 
education  of  children  (some  of  it  pretty  poor, 
it  must  be  admitted).  Is  compulsory  health 
HiSitSV*^  for  these  school  children  a  Utopian  dream,  or 
may  we  not  hope  that  this  may  one  day  be 
realised,  even  in  a  democracy? 


FACTORS  IN   NUTRITION  17 

With  conditions  as  they  are  today  in  the 
average  home,  and  in  the  present  state  of 
medical  knowledge  and  practice  in  the  greater 
part  of  this  country,  surely  the  State  must 
in  some  way  come  to  the  rescue  of  the  chil- 
dren. WHether  this  can  best  be  done  through 
Federal,  State  or  local  authorities  or  by 
cooperation  of  all  of  these,  as  our  roads  are 
built,  experience  must  determine.  x 

The  nutrition  of  the  child  is  dependent  ^ 
upon  three  factors :  The  character  and  quan- 
tity of  his  food ;  his  general  hygiene ;  and  his 
inheritance.  The  last  mentioned  we  cannot 
influence,  but  the  other  two  it  is  quite  within 
our  power  to  direct  and  control.  The  prob-  health  is 
lem  of  the  nutrition  of  the  child  then  is  a  ^""^"»^i«» 
soluble  problem  to  a  very  large  degree.  The 
slogan  of  the  New  York  Department  of 
Health,  that  ''public  health  is  purchasable," 
is  in  no  field  so  true  as  that  which  relates  to 
the  health  of  children.  Upon  the  nutrition  of 
the  children  depends  very  largely  the  future 
of  the  race  from  a  physical  standpoint,  and 
one  might  almost  say  from  an  economic  stand- 
point also. 

Every  live  thing  that  is  young  must  grow; 
growth  is  evidence  not  only  of  health  but  of 
life.  The  growth  of  the  body  is  conditioned 
by  its  nutrition.     That  not  only  the  health 


18 


FCK)D,    HEALTH  AND  GROWTH 


Orowth 
D«t«rmin*d 
"by  Food 


Food  of 

J&paiiM* 

ChUdran 


but  the  size,  weight,  vigour,  even  the  fertility 
of  animals  can  be  controlled  by  the  kind  of 
food  given,  has  been  demonstrated  in  many 
experimental  laboratories.  These  points  are 
most  easily  determined  with  small  animals 
like  rats  or  guinea  pigs  whose  life  cycle  is 
a  short  one.  That  the  same  biological  laws 
apply  to  the  human  race  is  beyond  ques- 
tion. 

The  opinion  was  once  held  that  the  stature 
of  certain  races  was  due  to  climate.  It  is 
now  generally  believed  that  these  racial  dif- 
ferences are  chiefly  the  result  of  differences 
in  food.  Of  course  chmate  affects  the  avail- 
able food  supply,  so  that  indirectly  it  is  an 
important  factor.  That  the  size  of  the  Jap- 
anese is  greatly  influenced  by  their  diet  dur- 
ing the  growth  period  can  hardly  be  doubted. 

Dr.  Hirai,  Professor  of  Paediatrics  in  the 
Imperial  University  of  Kyoto,  writes  me  in 
the  following  terms  in  response  to  my  inquiry 
concerning  the  usual  food  of  children  in 
Japan : 

''Rice  plays  the  most  important  part  in 
their  diet  after  infancy. 

*'No  milk,  cheese  or  butter  forms  a  part  of 
the  regular  diet. 

"The  fat  used  is  principally  vegetable 
oils. 


JAPANESE  CHILDREN  19 

"They  rarely  get  meat  but  take  much  fish. 

"Green  vegetables  are  extensively  eaten, 
especially  in  summer. 

"They  are  fond  of  sweets  and  consume 
much  of  them." 

This  diet  would  seem  clearly  to  be  deficient 
in  growth  proteins  and  probably  in  the  fat- 
soluble  vitamine  and  in  calcium. 

The  curves  for  weight  and  height  of  Jap- 
anese children,  for  which  I  am  also  indebted 
to  Professor  Hirai,  show  some  interesting 
comparisons  with  those  of  American  chil- 
dren. 

During  the  first  year  almost  no  difference 
is  seen.  But  after  infancy  when  the  general 
diet  is  taken,  the  divergence  of  the  curves 
both  for  height  and  weight  is  very  striking. 
I  have  had  no  opportunity  to  make  personal 
observations  upon  the  growth  of  the  Jap-  f^^^*^/^"  g 
anese  in  this  country ;  but  statistics  given  in  ^'1*^1^^" 
the  Report  of  the  Japanese  Educational  As- 
sociation of  America,  compared  ^\^th  those 
of  the  Educational  Department  of  the  City 
of  Tokio,  show  that  Japanese  children  in  the 
United  States,  both  boys  and  girls,  are  taller 
and  heavier  than  those  of  corresponding  ages 
living  in  Japan.  This  is  evident  in  spite  of 
the  fact  that  although  the  Japanese  diet  has 
undoubtedly  been  much  modified  by  residence 


20 


FOOD,    HEALTH   AND   GROWTH 


Better  Feed- 
ing and  Hy- 
giene In  In- 
fancy Pro- 
duce Better 
CbUdrm 


here,  it  is  still  very  different  from  the  Ameri- 
can diet  for  children. 

I  can,  however,  speak  from  personal  ob- 
servation upon  the  Russian  Jews.  Those 
adults  who  come  to  the  United  States  are  for 
the  most  part  scarcely  taller  than  the  Itahans. 
But  the  children  of  the  successful  and  pros- 
perous ones,  those  who  have  become  to  a  con- 
siderable degree  Americanised,  are  almost  as 
large  as  those  of  our  native-born  population ; 
the  children  are  frequently  four  or  five  inches 
taller  than  their  parents.  No  such  results 
of  emigration,  however,  are  seen  among  the 
very  poor,  whose  food  and  mode  of  life  have 
been  little  altered  from  those  of  their  par- 
ents. 

It  is  my  own  observation,  corroborated  by 
most  of  the  physicians  vriih  whom  I  have  dis- 
cussed the  subject,  whose  experience  entitles 
their  opinion  to  weight,  that  among  the  most 
intelligent  classes,  the  generation  of  Ameri- 
can boys  and  girls,  now  fully  gro\vn,  is  larger 
and  heavier  than  their  parents.  Newsholme 
states  that  the  same  thing  has  been  obser^'ed 
in  England  in  the  boys  at  Rugby.  This  re- 
sult is  due,  I  believe,  to  better  feeding  in  in- 
fancy and  early  childhood,  and  no  doubt  to 
increased  attention  given  to  out-of-door  in- 
terests during  the  period  of  growth.    As  yet, 


HEALTH  THE  CHILD 's  RIGHT  21 

however,  these  influences  have  affected  only 
a  small  fraction  of  the  children  of  the  coun- 
try. Owing  largely  to  a  climate  which  gives 
greater  opportunity  for  out-of-door  life,  the 
children  of  California  are  taller  and  heavier 
than  those  of  corresponding  ages  Uving  in 
the  East  and  ^Middle  West. 

To  ignore  the  mental  and  moral  aspects  of 
eugenics  and  endeavour  to  breed  a  race  of 
physical  supermen  and  women  is  not  exactly 
the  program  we  would  be  understood  as  advo- 
cating. We  do  not  in  this  age  give  so  high  a 
place  as  do  savage  and  barbarous  races  to 
physical  size  and  strength.  It  may  not  be 
thought  necessar^^  or  even  desirable  that  chil- 
dren should  be  as  large  as  possible  and  grow 
to  be  large  men  and  women. 

Happiness,  usefulness  and  even  success  in 
life  are  by  no  means  conditioned  upon  the 
height  and  weight  of  the  individual.  Still, 
a  fine  physical  development  is  everywhere 
regarded  as  an  asset  of  no  mean  value.  The 
handicap  in  life  of  a  frail  body  and  habitu- 
ally poor  health  is  a  very  serious  one.  We  rin« 
certainly  owe  it  to  every  boy  and  girl  to  give  U^AiMt 
them  the  opportunity  to  reach  the  best  phy- 
sical development  of  which  they  as  individu- 
als are  capable. 

The  effect  of  nutrition  upon  efficiency  ia 


22  FOOD,   HEALTH  AND  GROWTH 

one  of  its  most  interesting  aspects.  In  child- 
hood this  is  determined  chiefly  by  the  char- 
acter of  the  work  done  in  school.  There  is 
not  yet  a  great  deal  of  reliable  data  available 
upon  the  relation  of  nutrition  to  school  work. 
Most  of  those  who  have  studied  critically 
upon  a  large  scale  the  kind  of  work  done  in 
school,  have  considered  it  from  the  point  of 
view  of  the  teacher  rather  than  that  of  the 
physician. 

Studies  upon  retardation  in  school  have 
hitherto  dwelt  chiefly  upon  other  causes  than 
health,  such  as  late  entrance,  irregularity  of 
attendance,  etc.  Even  where  health  is  con- 
sidered at  all  it  is  usually  only  referred  to  as 
illness  which  keeps  a  child  from  school  or 
as  defects  of  hearing  or  vision  which  inter- 
fere wdth  school  work. 
Stf^uon*"  -^^  school  language  a  retarded  child  is  one 
that  is  below  his  grade  for  his  age.  Retarda- 
tion may  be  due  to  late  entrance,  but  in  very 
much  the  largest  number  of  cases — fully  two- 
thirds  it  is  estimated — those  who  are  retarded 
are  so  because  they  fail  of  promotion  and  are 
obliged  to  repeat  the  work  of  the  grade.  The 
problem  presented  by  this  group  of  children 
in  our  public  schools  becomes,  when  one  real- 
ises its  vast  extent,  a  very  important  one  to 
teachers  and  school  superintendents. 


NUTRITION   AND   SCHOOL   WORK  23 

Ayers,  who  has  made  for  the  Russell  Sage 
Foimdation  a  very  exhaustive  study  of  the 
problem  of  retardation  in  fifty-five  cities, 
found  the  average  number  of  retarded  chil- 
dren to  be  16  per  cent  of  the  pupils  en- 
rolled. It  is  a  question  which  involves  on 
the  basis  of  Ayers'  calculation  some  six  mil- 
lions of  children  in  the  United  States.  The 
cost  to  the  cities  of  the  country  alone  in  edu- 
cating this  retarded  group,  Ayers  estimates 
to  be  $27,000,000  a  year. 

What  particularly  concerns  us  now  is  how  J2i^oV°* 
large  a  part  health  and  general  nutrition  play 
in  school  retardation.  In  Ayers'  admirable 
monograph  the  subject  of  nutrition  is  not  even 
mentioned.  He  did  find,  however,  that  chil- 
dren with  physical  defects  made  definitely 
slower  progress  than  the  average. 

The  curriculum  of  the  elementary  schools 
is  theoretically  completed  in  eight  years.  The 
average  time  in  which  this  was  done  in  thirty- 
one  cities  studied  by  Ayers  was  nine  and  a 
third  years.  In  six  cities  the  average  time 
was  more  than  ten  years.  These  were  in 
every  instance,  I  believe,  cities  wdth  excep- 
tionally bad  health  records.  While  not  estab- 
lishing a  relationship  between  health  and 
retardation  these  facts  are  certainly  sug- 
gestive. 


Grade 


24  FOOD,   HEALTH  AND  GROWTH 

As  far  back  as  1893  Porter's  observations 
in  St.  Louis  showed  that  the  children  who 
gave  evidence  in  their  school  work  of  more 
s^SSS*  "*  than  average  capacity,  as  measured  by  prog- 
ress in  their  studies,  were  both  taller  and 
heavier  than  their  companions  of  the  same 
ages  whose  work  was  inferior.  He  gives  the 
weights  of  1736  boys,  eleven  years  old.  They 
■were  in  all  school  grades  from  the  first  to  the 
sixth.  The  average  weight  increased  regu- 
larly with  the  advance  in  grade.  For 
example : 

The  averajre  weiifht  of  eleven-year-old  boys  in  flnt  grade  wti  63.4  lb. 
"  "  "        "        "        "      "       "      "   sixth     "        "      73.2    " 

Similar  results  were  observed  in  the  weight 
of  girls. 

The  average  weight  of  thirte«n-year-(dd  girls  in  third  grade  wai  76.2  lb. 
"  "  "       •<        •'  "      "       "     "  seventh  "       "    88.4    " 

That  there  is  a  close  correspondence  be- 
tween physical  development  and  mental  prog- 
ress in  school  has  been  confirmed  by  no  less 
than  eighteen  subsequent  investigations  in 
the  United  States,  besides  others  published 
elsewhere  from  Canada,  Germany,  Russia, 
etc. 

The  follo"^ang  are  some  of  the  conclusions 
stated  by  those  making  the  studies: 


NUTRITION  AND  SCHOOL  WORK  25 

"Physical    development    and    intellectual  Pi»y«ic»i 

•'  ^  and  Mental 

ability  are  closely  connected."  Stltoioiai 

"Physical  and  mental  conditions  are  in-  »^t^ 
terdependent. ' ' 

"Groups  ahead  in  grade  are  taller  and 
heavier  than  groups  of  average  grade." 

"Tall  and  heavy  boys  and  girls  are  phy- 
siologically older  and  further  advanced  in 
school  progress  than  those  who  are  small 
and  light." 

"School  progress  goes  hand  in  hand  with 
physical  development. ' ' 

"Bright  boys,  as  shown  by  school  progress, 
are  better  developed  physically  and  heavier 
for  height  than  retarded  ones." 

"There  is  a  positive  correlation  between 
physique  and  intelhgence;  the  largest  boys 
are  in  the  highest  grades." 

The  conclusion  reached  by  those  who  have 
studied  this  question  is  practically  a  unani- 
mous one,  that  mental  development  parallels 
physical  development. 

Two  recent  investigations,  one  in  Washing- 
ton and  one  in  Detroit,  deserve  special  notice 
because  they  have  been  made  since  the  sub- 
ject of  nutrition  has  been  brought  particu- 
larly to  notice. 

In  1919  Bryant  made  under  the  auspices  of 
the  Child  Health  Organisation  a  survey  of 


26 


POOD,    HEALTH   AND   GROWTH 


the  school  children  in  Washington,  particu- 
larly as  to  their  nutrition.  One  thousand  ten- 
year-old  children  were  studied;  this  age  be- 
ing the  middle  of  the  school  period,  it  was 
thought  would  show  an  average  of  school 


mrreiTiON  im  school  mtnu  -  uwiwTeii.  o-c 


JU2U 


MmiTioH  MOO         Numnoii  mo*         HvntmoM  cooo         ■uTtrrio*  not 


-e- 


JUIU 


A 


1 


A 


I  I  PC*  cerr  of  cmuxcn  maxim  rapio  motmn- 

■■■    -      -     .       -  sum 

Fig.  1. 

conditions.  She  found  ten-year-old  children 
in  all  the  grades  from  the  first  to  the  seventh. 
The  proportion  of  those  "svith  good  nutrition 
was  twice  as  great  in  the  three  upper  grades 
as  the  three  lower  grades.  Among  the  boys, 
rapid  progress,  i.e.,  skipping  one  or  more 
grades,  was  obser^'ed  in  7  per  cent  of  those 
well  nourished  and  in  none  of  those  poorly 


NUTRITION   AND   SCHOOL   WORK  27 

nourished.  Slow  progress,  i.e.,  repeating  one 
or  more  grades,  was  seen  in  22  per  cent  of 
those  well  nourished  and  in  37  per  cent  of 
those  poorly  nourished.  The  difference  in  the 
school  standing  of  the  girls  according  to  the 
condition  of  their  nutrition  was  similar  but 
not  quite  so  marked.  Among  them  rapid  pro- 
gress was  observed  in  5  per  cent  of  the  well 
nourished  as  compared  with  9  per  cent  of  the 
poorly  nourished.  Slow  progress  w^as  seen 
in  13  per  cent  of  the  well  nourished  and 
in  21  per  cent  of  the  poorly  nourished.    (Fig. 

1.) 

The  conclusion  reached  from  this  study  was 
that  among  boys,  especially,  poor  nutrition  SfiJn^Es- 
distinctly  handicaps  progress  in  school;  ex-  toe^Bi^'^ 
cellence  in  school  progress  is  dependent  upon 
good  nutrition ;  a  boy  must  be  well  nourished 
to  attain  more  than  average  grade  or  go  fas- 
ter than  his  fellows. 

A  study  w^as  published  in  1921  by  Packer 
and  Moehlman  of  a  survey  made  in  the  City 
of  Detroit,  which  covers  observations  upon 
height,  weight,  age  and  school  standing  of 
84,389  children.  With  but  few  exceptions, 
at  every  age  from  six  to  fourteen  and  a  half 
years,  the  degree  of  retardation  or  accelera- 
tion in  school  work,  corresponded  very  closely 
with  the  body  weight.    This  is  sho\\ai  in  the 


Scbool  Work 


28 


POOD,    HEALTH   AND   GROWTH 


■tlOHT  AND  SCHOOL  PROGRESS. 
41.151   DETROIT  BOYS. 


TEARS   RETARDED 

3  2    I  as 


WEICHT  ACCELERATED  -  PER  CENT 
102 


II 


2jB 

I 


0yiTS223 
YEARS    ACCELERATED 


WEICHT  RETARDED -PER  CENT 

Fio.  2. 

chart  (Fig.  2)  which  gives  the  relationship 
between  weight  and  school  progress  of  41,151 
boys.  The  weight  of  5987  boys  who  were  in 
the  normal  grade  for  age  is  taken  as  100  per 
cent. 


NUTRITION  AND  SCHOOL  WORK  29 

The    weight    of    boy»    retarded    1    year    was    1.5    per    cent    below    th« 

average  weight  for  the  gp^de. 
The   weight    of    boys    retarded    2    years    was    2.6    per   cent    below   the 

average  weight  for  the  grade. 
The   weight   of    boya    retarded    3    years    was    4.9    per   cent    below    the 

average  weight  for  the  grade. 
The   weight   of    boys    retarded    4    years   was    8.1    per   cent    below    the 

average  weight  for  the  grade. 
The   weight   of   boys   accelerated   1   year  was   2.6   per   cent   above  the 

average  weight  for  the  grade. 
The   weight   of   boys   accelerated    l^i    years   was    5   per   cent   above  the 

average  weight  for  the  grade. 
The  weight   of  boys   accelerated   2   years   was   7.1   per  cent  above  the 

average  weight  for  the  grade. 
The  weight  of  boys  accelerated  2Vi  years  was  10.2  per  cent  above  the 

average  weight  for  the  grade. 

The  accelerated  children  were  for  the  most 
part  in  the  lower  ejrades.     After  the  tenth  cwidrenBe- 

^  °  low  Aver- 

year  the  number  of  the  retarded,  and  of  those  as*  weight; 

•'  '  Accelerated 

who  were  below  average  weight,  steadily  in-  J^^J^^*"^ 
creased.  At  the  age  of  fourteen  and  a  half 
there  were  no  accelerated  children  but  many 
retarded  and  many  below  average  weight. 
The  charts  for  the  girls  were  very  similar, 
but  a  little  less  regular  than  those  of  the  boys. 
In  some  of  the  upper  grades,  girls  were  more 
frequently  found  above  average  weight  but 
below  their  grade  than  was  the  case  with 
boys;  but  in  both  sexes  these  exceptions  to 
the  general  rule  were  surprisingly  few. 

These  and  many  other  data  fully  confirm 
all  the  other  studies  made  upon  the  question, 
that,  as  a  rule,  children  physically  well  de- 
veloped and  well  nourished  do  better  school 


30 


FOOD,   fiEALTH  AND  GBOWTH 


Good  School 
Work  Can- 
not b« 
Ezp*ct«d  of 
Mjd- 

iiourished 
OUldren 


work  than  those  of  inferior  physique  and  who 
are  undernourished.  Poor  nutrition,  further- 
more, is  a  frequent  reason  for  children  be- 
ginning school  late,  and  also  for  frequent  ab- 
sences for  minor  illnesses  to  which  these  chil- 
dren are  so  liable.  Both  of  these  conditions 
tend  to  increase  the  amount  of  retardation 
seen  in  this  group  of  pupils. 

The  problem  of  the  nutrition  of  school  chil- 
dren and  its  bearing  upon  progress  in  school 
work  is  one  whose  importance  teachers  and 
school  boards  have  not  as  yet  appreciated. 
To  expect  an  underfed,  malnourished  child  to 
profit  by  educational  advantages,  no  matter 
how  superior  these  may  be,  is  a  grievous 
error.  The  old  saying  that  it  is  hard  for  an 
empty  bag  to  stand  upright,  is  nowhere  more 
true  than  here.  You  cannot  fill  the  head  when 
the  stomach  is  empty;  nor  can  you  expect 
application  or  concentration  of  mind  from  an 
anaemic,  nervous  child  who  is  fifteen  or  twenty 
pounds  below  normal  weight.  In  such  cir- 
cumstances a  large  part  of  the  time  and  en- 
ergy of  the  teacher  is  wasted  effort. 

An  interesting  study  of  the  mental  and 
nervous  manifestations  in  school  children  as 
a  result  of  malnutrition  was  made  by 
Blanton  of  Wisconsin  when  he  was  with  the 


NUTRITION  AND  SCHOOL  WORK  31 

Army  of  Occupation.  He  made  observations 
upon  6500  children  in  Trier,  Germany.  He 
found  that  at  least  40  per  cent  were  suffering 
from  malnutrition  to  a  degree  causing  loss 
of  nervous  energy;  double  the  usual  number 
failed  to  pass  their  grades;  the  number  do- 
ing superior  work  was  reduced  by  one-half, 
and  the  number  doing  inferior  work  was  in- 
creased by  50  per  cent.  The  most  striking 
symptoms  noted  among  the  malnourished 
children  were  (1)  lack  of  energy;  they  were 
easily  fatigued  mentally  and  physically, 
would  often  fall  asleep  in  school;  (2)  inat- 
tention, it  was  difficult  to  hold  their  minds  to  Nervoua 
any  subject  but  a  few  minutes  at  a  time;  (3)  nfuSde™' 
poor  memory,  closely  associated  with  inatten-  chudrea 
tion,  for  instance  it  took  the  children  thirty 
minutes  to  memorise  a  few  lines  which  or- 
dinarily could  be  done  in  half  the  time,  and 
it  seemed  almost  impossible  to  remember 
arithmetic;  (4)  slow  comprehension;  as  one 
teacher  put  it,  **it  takes  the  children  longer 
to  think";  they  found  it  difficult  to  follow 
explanations;  (5)  unusual  restlessness,  the 
children  could  not  sit  still,  they  either  wanted 
to  talk  or  giggle  or  whisper  and  it  was  diffi- 
cult to  maintain  discipline,  and  misbehaviour 
was  common.    Other  groups  were  unusually 


32  FOOD,  heaijTH  and  growth 

dull  and  quiet  and  immobile  and  seemed  men- 
tally stupid. 

We  all  recognise  this  group  of  symptoms, 
they  are  familiar  ones  to  every  school  teacher, 
but  not  always  referred  to  their  proper  cause. 
Many  of  these  children  would  be  classed  as 
mentally  dull  or  stupid,  proper  subjects  for 
an  ungraded  class,  when  the  real  cause  is 
malnutrition. 

The  conclusion  seems  to  be  fully  justified 
that  there  is  a  physical  basis  for  dulness  or 
brightness  in  school  work.  If  better  work  is 
to  be  done  in  school  by  the  average  pupil,  his 
nutrition  and  physical  development  must  be 
improved.  In  the  large  problem  of  school 
retardation  I  believe  it  will  be  found  to  be 
one  of  the  most  important  factors ;  that  it  has 
received  so  little  attention  in  the  past  seems 
most  surprising. 

The  nutritional  problem  presented  by  the 
school  child  is  part  of  the  educational  prob- 
lem, and  must  be  recognised  as  such  by  both 
Kutrttion,      teachers  and  school  boards.    It  might  prove 

Part  of  P       1 

prow«i°*^  a  matter  of  economy  if  some  part  of  the 
twenty-seven  millions  now  expended  in  this 
country  annually  in  teaching  retarded  pupils 
were  devoted  to  health  education  and  hot 
school  lunches  to  improve  their  nutrition. 
An  interesting  sidelight  upon  the  relation- 


RESISTANCE  TO  D1SE:ASE  33 

ship  between  physical  development  and  men- 
tal capacity  is  afforded  by  a  study  of  the 
weight  and  height  of  defective  children.  In 
Goddard's  report  upon  6480  defective  chil- 
dren from  nineteen  institutions  it  was  sho^vn 
that  the  physical  deviation  from  the  normal 
was  regularly  proportionate  to  the  degree  of 
mental  deficiency.  He  concludes  that  there 
is  a  definite  and  a  remarkable  correlation  be- 
tween physical  growth  and  mental  develop- 
ment. When  large  groups  are  considered, 
feeble  mental  capacity  goes  with  small  bodies. 

For  the  physician  one  of  the  most  interest- 
ing phases  of  nutrition  is  its  bearing  upon 
the  question  of  resistance  to  infection.  Ex- 
perimental animals  when  deprived  of  certain 
foods,  those  containing  the  fat-soluble  vita- 
mine,  for  example,  show  a  great  suscepti- 
biUty  to  bacterial  infections  and  a  very  high 
death  rate  from  them,  especially  those  of  the 
lungs. 

With  the  great  majority  of  diseases  the 
state  of  nutrition  has  a  very  important  rela- 
tion to  resistance  to  infection.  This  is  showTi 
both  in  laboratory  experiments  and  in  clini-  and  k*- 

■Istanca  to 

cal  experience.  infection 

Dr.  Trudeau's  early  experiments  with 
tuberculosis  afford  an  excellent  illustration. 
Young  guinea  pigs  in  all  respects  as  nearly 


34  FOOD,    HEALTH  AND   GROWTH 

alike  as  possible  were  inoculated  with  tubercle 
bacilli  in  the  same  manner  and  with  the  same 
doses.  One  group  had  good  food,  sunshine, 
fresh  air,  in  short  all  the  conditions  required 
for  normal  nutrition.  The  other  group  were 
given  none  of  these  things  but  were  confined 
where  they  had  to  live  under  unhygienic  and 
unfavourable  conditions.  The  first  group  re- 
covered from  their  infection,  grew  and  gained 
weight,  thrived  normally  and  when  finally 
killed  the  lesions  produced  by  the  infection 
were  found  to  be  cured.  They  had  entirely 
recovered.  The  second  group  lost  ground 
steadily  after  inoculation  and  all  succumbed 
to  tuberculosis  in  the  course  of  a  few  weeks 
or  months. 

Upon  these  and  similar  experiments  the 
whole  modern  treatment  of  tuberculosis  has 
been  built  up.    Our  clinical  observations  con- 
firm the  results  seen  in  animals.     Infection 
by  the  germs  of  tuberculosis  is  very  wide- 
SStriti^       spread,  but  its  active  development  in  an  in- 
vfiopmLStf  dividual  is  most  frequently  due  to  conditions 
cuiosia  which  have  lowered  bodily  resistance  by  im- 

pairing   nutrition.      The    campaign    against 
tuberculosis  has  become  essentially  one  for 
improving  nutrition  by  food  and  personal  hy- 
giene. 
The  most  striking  illustration  of  diminished 


BESISTANCE  TO  DISEASE  35 

resistance  to  infection,  o\ving  to  impaired  nu- 
trition, is  not  only  the  remarkable  increase  of 
tuberculosis  and  all  infections  in  children  in 
those  parts  of  Europe  where  war  conditions 
bore  most  heavily,  but  also  the  very  high 
mortaUty  from  these  diseases. 

Nowhere  perhaps  is  the  influence  of ''nutri- 
tion upon  resistance  to  infection  seen  to  a 
greater  degree  than  in  the  common  infections 
of  infancy.  A  robust  infant  admitted  to  a 
hospital  for  a  surgical  condition  may  remain 
for  weeks  in  excellent  health.  But  the  infant 
whose  nutrition  is  much  below  the  normal 
is  so  susceptible  that,  in  spite  of  the  utmost 
precautions,  he  contracts  infections  due  to 
common  pyogenic  bacteria  which  excite  in- 
flammations, especially  of  the  respiratory 
tract,  frequently  with  most  serious  conse- 
quences. 

It  is  almost  impossible  in  winter  to  keep 
such  infants  in  a  hospital  ward  more  than  a 
week  or  two  without  their  developing  rhino- 
pharj^ngitis,  otitis,  bronchitis  or  broncho- 
pneumonia.    The  dilference  in  the  way  the 

.  .  ,  I   i      •     c      i'  •  1       Susceptlbll- 

two  tjTDes  also  react  to  miection  is  veiy  great,  ityof  Deu- 
The  robust  infant,  as  a  rule,  soon  throws  it  dren  to 
off ;  in  the  poorly  nourished  child,  apparently 
mild  infections  frequently  follow  one  after 
another  until  the  child  finally  succumbs  to 


iLlectlon 


36 


FOOD,    HEALTH   AND   GROWTH 


M&intalnlng 
Kutrltlon 
Important 
P*rt  of 
Treatment 
of  Diaeue 


their  combined  effects.  It  is  for  this  reason 
that  hospitals  for  infants  have  such  limita- 
tions in  their  usefulness.  Roomy  wards  mth 
ample  space  between  beds  and,  most  of  all 
the  cubicle  system  of  construction,  will  do 
much  to  lessen  the  dangers  from  infection  in 
these  susceptible  patients ;  but  they  can  never 
altogether  overcome  them. 

Again,  the  outcome  of  attacks  of  pneu- 
monia, empyema,  typhoid  fever,  or  dysen- 
tery and  many  other  infections  is  dependent 
in  no  small  degree,  first,  upon  the  previous 
nutrition  of  the  child  and,  secondly,  upon 
our  abiUty  to  maintain  nutrition  during  the 
period  of  acute  illness. 

Notwithstanding  all  the  time  and  labour 
that  have  been  expended  in  the  search  for 
specific  remedies  for  disease,  the  list  of  those 
in  which  this  has  been  achieved  is  a  very  short 
one.  Malaria,  sj^Dhilis,  diphtheria,  cerebro- 
spinal meningitis,  and  certain  types  of  pneu- 
monia practically  complete  the  list. 

For  a  long  time  to  come,  from  present  indi- 
cations, it  ^vill  be  the  duty  of  the  physician 
to  treat  the  patient  suffering  from  the  disease 
rather  than  the  disease  itself;  in  the  treat- 
ment of  the  patient  we  have  come  to  realise 
that  nothing  is  so  important  as  to  maintain 
his  nutrition  by  careful  feeding  and  hvgione. 


BESISTANCE  TO  DISEASE  37 

But  it  is  not  only  the  child  who  is  much 
under  weight  whose  state  of  nutrition  renders 
him  peculiarly  liable  to  infection.  There  are 
large,  fat,  flabby  children,  especially  infants, 
who  seem  quite  as  susceptible  to  infection 
and  to  exhibit  as  little  resistance  when  in- 
fected. This  appears  to  be  related  to  the 
chemical  composition  of  the  body  which  to 
a  certain  degree  is  dependent  upon  the  diet. 
Infants  whose  diet  is  excessive  in  carbohy- 
drates and  low  in  protein  and  fat  form  one  of 
these  groups.  The  laity  often  make  a  dis- 
tinction between  good  fat  and  flabby  fat. 
This  idea  contains,  I  think,  a  hint  of  the  true  cnudren  not 
explanation.  It  is  well  known  that  such  a  diet 
as  that  mentioned  tends  to  a  rapid  increase  in 
weight  without  a  corresponding  increase  in 
strength.  A  familiar  example  of  this  type 
is  the  typical,  condensed-milk  baby.  Observa- 
tions upon  animals  indicate  tliat  a  consider- 
able part  of  this  weight  is  due  merely  to  ex- 
cessive retention  of  water  in  the  tissues  of  the 
body,  and  that  this  is  regularly  increased  by 
increasing  the  proportion  of  carbohydrate 
in  the  diet.  Infants  of  the  typo  mentioned  are 
peculiarly  liable  to  diseases  of  the  digestive 
tract  and  show  but  little  resistance  when  at- 
tacked. 

The  rapid  and  almost  incredible  loss  in 


HMathy 


88  POOD,   HEALTH  AND  GROWTH 

weight  which  these  infants  suffer  with  an 
acute  diarrhceal  attack  is  of  course  due  sim- 
ply to  the  draining  away  of  water  from  the 
tissues,  and  in  them  the  loss  is  much  greater 
as  the  water  held  in  the  tissues  is  greater. 

In   chronic   disease    during   infancy    and 
childhood  the  result  depends  very  largely 
upon  our  ability  to  maintain  normal  nutrition. 
What  has  been  said  regarding  tuberculosis 
applies  almost  equally  well  to  cardiac  dis- 
M«totOTance  ease    during   this   period.     This    has   been 
p2rt^o/*to«»    shown  very  clearly  in  the  cardiac  clinics  in 
J/^huSen    New  York.     The  problem  of  the  child  with 
S?rt°^"'^''  cardiac  disease  has  come  to  be  regarded  as 
Di>ea8«        very  largely  a  problem  in  nutrition,  and  it 
differs  in  no  very  essential  features  from  the 
problem  of  the  undernourished  child  when 
the  cause  is  a  different  one.    Quite  as  impor- 
tant is  constant  supervision  of  diet  and  gen- 
eral hygiene,  and  even  more  important,  the 
necessity  for  a  proper  adjustment  of  rest  and 
activity.     Provided  nutrition  can  be  main- 
tained w^th  these  patients  during  the  period 
of  growth,  the  groat  majority  of  them  reach 
adult  life  with  so  little  crippling  that  they  are 
not  seriously  handicapped.    But  how  differ- 
ent is  the  outlook  for  cardiac  cases  among  the 
poor  or  ignorant,  where  the  conditions  of 
proper  nutrition  have  been  impossible  or  have 


NUTRITION  AND  REPAIR  39 

been  neglected.  Dilatation  of  the  heart  in- 
creases ;  compensation  soon  fails.  With  treat- 
ment by  rest,  proper  feeding  and  care  their 
most  aggravated  symptoms  are  temporarily 
relieved,  but  too  often  soon  return.  The  heart 
each  time  is  left  a  little  worse  than  before 
until  finally  the  condition  becomes  a  hopelesa 
one  and  death  follows. 

It  is  not  then  any  special  treatment  which 
the  average  child  with  a  cardiac  lesion  re- 
quires, but  only  continuous  intelligent  super- 
vision of  his  hygiene  and  nutrition.  If  these 
are  neglected  no  amount  of  medication  can 
prevent  a  steady  advance  in  the  pathological 
condition  of  the  heart. 

Growth  and  repair,  while  not  identical,  are 
very  closely  related  processes,  and  are  influ- 
enced by  much  the  same  conditions.    Repair 
after  injury  can  take  place  at  any  age,  but  J^**"^'"" 
it  is  much  more  active  during  the  growth  pe-  Jj^^j.**"  m. 
riod.    At  all  ages  it  is  greatly  influenced  by  Nutritlon^^ 
the  state  of  nutrition  of  the  patient.    This  is 
even  more  true  of  repair  after  the  lesions  of 
disease  than  after  those  produced  by  injurj'. 

In  all  organic  disease  recovery  is  greatly 
aided  by  the  fact  of  growth.  Provided  nor- 
mal nutrition  can  be  maintained,  growth 
makes  possible  a  degree  of  repair  of  organs 
damaged  by  disease  to  a  degree  that  those 


40  POOD,   HEALTH  AND  GROWTH 

who  are  familiar  with  the  repair  of  the  adult 
organs  can  hardly  appreciate.  Within  cer- 
tain limitations  children  may  actually  out- 
grow an  organic  disease. 

In  all  chronic  disease  in  childhood  the  or- 
ganism has  a  twofold  task:  first,  to  combat 
the  pathological  process  and  repair  the  dam- 
age which  it  has  wrought;  secondly,  at  the 
same  time,  tot  provide  for  growth.  It  is 
often  impossible  for  the  body  to  do  both  these 
things,  and  gro^vih  is  always  what  suffers. 
The  effect  upon  growth  of  certain  types  of 
chronic  nephritis  is  so  marked  as  to  give  rise 
to  the  term  ''renal  dwarfism." 

But  when  the  pathological  process  is  one 
which  affects  the  organs  specially  connected 
with  nutrition,  like  those  of  the  digestive 
tract,  the  consequences  are  the  most  serious. 
As  a  result,  in  some  disorders  like  that  com- 
monly known  as  chronic  intestinal  indiges- 
tion in  its  severe  form,  grow^th  may  be  ar- 
rested for  years,  so  long,  in  fact,  that  it  is 
never  entirely  made  up  and  the  child  is 
dwarfed  for  life.  "Intestinal  infantilism" 
the  condition  is  often  called. 

When  we  turn  now  to  consider  the  func- 
tional disorders  of  childhood  the  question  of 
initrition  assumes  a  still  more  important  role. 


NUTRITION  AND  REPAIB  41 

The  rapid  growth  of  the  brain  and  the  de- 
velopment of  the  nervous  system  render  the 
growing  child  peculiarly  susceptible  to  ner- 
vous disturbances,  whenever  conditions  of  life 
are  such  as  to  interfere  with  normal  nutrition. 
Most  of  the  neuroses  of  childhood  depend  en- 
tirely upon  disorders  of  nutrition.    The  head- 
aches, insomnia,  disturbed  sleep,  chorea,  habit  Snli'^?^. 
spasm,  hysterical  manifestations  and  a  mul-  Sr  cSd*r*Si*' 
titude  of  others  are  relieved  only  by  correct-  ordered  *' 
ing  the  faulty  diet  and  habits  which  are  the 
basis  of  the  disturbed  nutrition. 

The  relation  of  nutrition  to  surgical  results, 
surgeons  are  only  just  beginning  to  appre- 
ciate. Those  obtained  in  chronic  bone  or 
joint  diseases,  for  example,  depend  far  more 
upon  the  patient's  nutrition  than  upon  the 
technical  skill  with  which  an  operation  is  done 
or  mechanical  appliances  used. 

The  impulse  of  all  young  things  to  grow  is 
a  verj'^  strong  one.  It  can  be  held  in  abeyance 
ill  various  ways  for  considerable  periods, 
when,  if  the  conditions  which  have  inhibited 
growth  are  removed,  the  loss  can  be  made  up. 
But  if  the  cause  continues  to  operate  for 
too  long  a  time,  the  normal  growth  response 
is  no  longer  present  and  permanent  dwarfing 
of  the  body  is  the  result. 


42  FOOD,    HEALTH   AND   GROWTH 

Experiments  upon  young  animals  prove 

SSiuS)^'    that  growth  can  be  arrested  at  any  time  and 

SS'fMiing  for  long   periods    simply  by   underfeeding, 

p«rio<u        "v^hich  may  be  done  in  a  great  variety  of  ways, 

withholding  one  or  another  of  the  necessary 

elements  of  food. 

It  has  been  shown  that  with  dogs,  if  the  pe- 
riod of  underfeeding  did  not  continue  through 
the  entire  period  of  adolescence,  animals  were 
still  capable  of  growing  vigourously;  but  if 
the  inhibition  extended  through  the  custom- 
ary growth  period,  the  capacity  for  growth 
was  lost.  A  healthy  j^oung  dog  was  kept 
for  ten  months  upon  a  diet  which  did  not 
promote  growi;h,  but  was  still  sufficient 
to  maintain  weight.  Afterwards  the  ani- 
mal was  given  a  full  diet.  A  considerable 
increase  in  weight  occurred  but  very  little 
growth. 

Osborne  and  Mendel's  white  rats  grew  vig- 
ourously after  growth  had  been  inhibited  by 
underfeeding  for  as  long  periods  as  ten  and 
twelve  months.  This  represents  in  these  ani- 
mals about  one-third  of  the  life  cycle,  and  it 
is  a  longer  period  than  is  usually  required  to 
complete  normal   growth. 

Data  are  lacking  as  to  what  are  the  ulti- 
mate effects  upon  children  of  prolonged 
underfeeding.     We   constantly  see  in  indi- 


PROLONGED  UNDERFEEDING  43 

viduals  early  retardation  of  growth  made  up  t^^.'^^  3 
by  abnormally  rapid  growth  at  a  later  period,  **•<*•  ^» 
when  the  cause  of  the  retardation  is  not  con- 
tinued and  especially  when  the  cause  is  not 
some  organic  or  pathological  condition. 

Children  in  Vienna  recently  observed  by 
Noel  and  Paton  of  England  showed  an  aver- 
age of  17.5  per  cent  below  standard  weight, 
some  were  as  much  as  27  per  cent  below. 
The  group  averaged  8  per  cent  below  stand- 
ard height.  These  figures  indicate  that  the 
children  were  nearly  four  years  below  normal 
weight  and  nearly  three  years  below  normal 
height  for  their  respective  ages. 

What  mil  be  the  ultimate  effect  of  six  or 
seven  years  of  underfeeding  of  the  children 
in  some  of  the  European  countries?  That  it 
will  affect  stature  seems  certain.  Will  it  also 
affect  fertility  or  longevity?  We  do  not 
know.  The  powers  of  recuperation  in  child- 
hood are  certainly  very  great.  But  there  are 
limits  beyond  which  nature  Anil  not  go.  It 
is  probable  thaf  many  permanent  results  men- 
tioned may  be  seen,  particularly  in  individ- 
uals who  were  originally  of  poor  phvsical  its  conse- 

.  Quences  Per- 

stock.    If  to  prolonged  underfeeding  we  add  manent 
chronic  disease,  which  has  developed  in  so 
many  as  a  result  of  such  feeding,  and  other 
unfavourable  conditions,  the  inevitable  con- 


44  POOD,    HEALTH   AND   GROWTH 

sequences  would  seem  to  be  permanent  stunt- 
ing of  growth,  a  high  mortality  in  early  adult 
life,  greatly  impaired  physical  energy,  low^- 
ered  mental  capacity  and  premature  old  age. 

Enough  illustrations  have  already  been 
given  to  show  that  both  to  the  physician  and 
to  the  surgeon  a  personal  knowledge  of  nutri- 
tion, or  at  least  an  appreciation  of  its  impor- 
tance in  the  work  of  each  of  them,  is  abso- 
lutely indispensable  if  they  would  success- 
fully combat  disease  during  the  period  of 
growth.  To  the  nurse,  the  parent  and  the 
teacher  also,  a  knowledge  of  the  fundamental 
principles  of  nutrition  is  essential  if  they 
are  to  be  equal  to  their  responsibilities  re- 
garding children. 

It  remains  to  consider  very  briefly  certain 
definite  pathological  processes  which  are  pro- 
duced by  failures  in  diet  to  supply  some 
things  which  are  essential  to  normal  nutri- 
tion. The  list  of  these  so-called  "deficiency 
diseases"  is  not  a  long  one,  but  they  form  an 
important   group. 

In  scurvy  it  is  well  established  that  its  cause 
is  a  diet  lacking  in  an  essential  accessory  food 
substance — the  antiscorbutic  vitamine.  In 
beri-beri,  a  disease  rare  in  this  country  but 
common  in  certain  parts  of  Asia,  the  cause  is 
a  lack  of  another  of  these  substances,  com- 


DEFICIENCY  DISEASES  45 

monly  referred  to  as  the  water-soluble  vit- 
amine.  A  disease  is  produced  in  animals  in 
which  the  most  prominent  symptom,  inflam- 
mation of  the  eyes,  goes  on  unless  arrested  to 
complete  destruction  of  the  organ  and  known  ??d",J^j^4„ 
as  xerophthalmia.  A  closely  analogous  ^^^^ 
one,  if  not  identical  with  it,  kerato-malacia,  is 
met  with  in  children.  Both  these  conditions 
are  due  to  a  lack  in  the  diet  of  another  acces- 
sory food  substance,  known  as  the  fat-soluble 
vitamine. 

There  are  two  other  common  diseases  of  nu- 
trition— rickets  and  pellagra — which  are 
closely  associated  with  defective  diets,  but  in 
which  the  evidence  is  not  conclusive  that  they 
are  due  to  the  absence  of  a  specific  accessory 
food  substance  or  vitamine. 

In  forecasting  the  future  of  medicine  as  it 
relates  to  children  it  seems  likely  that  prog- 
ress will  be  made  as  wo  are  able  to  solve  the 
problem  of  the  acute  infections,  and  that  of 
nutrition.     The  problem  of  the  acute  infec-  fiMm/'o? 
tions  is  likely  to  be  solved  by  measures  of  ^e^Rlce^ 
prevention  rather  than  by  the  discovery  of  Nutfiuo" 
specific    forms    of    treatment.      Preventive  oro^ 
measures   will   include   not   only   sanitation, 
quarantine,  isolation  and  the  development  of 
preventive  sera,  but  quite  as  important  per- 
haps as  any  of  these,  increasing  the  resist- 


46  FOOD,    HEALTH   AND   GROWTH 

ance  of  children  by  improving  their  nutri- 
tion. This  is  the  most  hopeful  field  of  pre- 
ventive medicine. 

With  chronic  organic  disease  we  have  in 
childhood  almost  nothing  to  do  except  as  a  se- 
quel of  acute  processes,  which  are  usually  the 
result  of  infection. 

In  infancy  fully  half  the  total  deaths  are 
still  directly  traceable  to  disorders  of  nutri- 
tion. Though  greatly  reduced  from  former 
figures,  infant  mortality  is  still  unnecessarily 
high.  Improvement  of  conditions  in  infancy 
will  be  reflected  also  in  improved  results  in 
early  childhood. 

It  is  not  too  much  to  expect  that  with  a 
better  understanding  of  the  subject  of  nu- 
trition there  may  be  accomplished  for  the 
older  child  something  comparable  to  what 
has  been  done  for  the  infant.  We  may  per- 
haps not  see  a  greatly  reduced  death  rate 
but  we  shall  surely  see  a  much  higher  stand- 
ard of  physical  development  and  general 
health. 


CHAPTER  n 

« 

Lecture  Two 

The  Amount  of  Food  Bequired  by  Children 

The  food  requirements  of  children  have 
been  discussed  from  many  points  of  view. 
By  different  investigators  various  phases  of 
this  general  subject  have  been  studied.  One 
group  has  been  devoting  its  attention  to  basal 
metabolism,*  or  the  needs  of  the  body  at  rest. 
Others  have  taken  up  the  study  of  the  pro- 
tein requirement  and  the  growth  properties 
of  certain  proteins ;  still  others,  the  total  food 
requirement  for  children  in  terms  of  calo- 
ries.**  Just  now  the  attention  of  investi-- 
gators  is  focussed  upon  the  accessory  food 
substances — the  so-called  vitamines. 

The  estimates  w^hich  have  been  made  re- 

*  The  term  metabolism  is  used  to  cover  all  the  chemical 
changes  taking  place  in  the  body  cells  and  in  foodstuffs 
after  absorption,  before  their  products  are  eliminated. 

**  A  calorie  is  an  arbitrary  heat  unit.  It  is  the  same 
whether  the  heat  is  produced  from  coal,  gasoline,  or  food 
taken  into  the  body.  It  is  the  amount  of  heat  required 
to  raise  one  litre  of  water  (about  ono  quart)  from  zero 
to  1°  C. 

47 


Small  Ktim- 
ber  of  Ob- 
aerratlons 
WhlcbHsTd 
BMnMad» 


48  FOOD,    HEALTH   AND   GROWTH 

garding  the  total  food  needs  of  children  have 
sometimes  been  purely  hypothetical,  but  more 
generally  based  upon  the  requirements  of 
adults.  Observations  made  during  the  last 
few  years,  especially  in  this  country,  have 
thrown  new  light  on  this  subject. 

In  reviewing  the  older  literature,  w^hich  is 
chiefly  German,  one  is  struck  with  the  small 
number  of  the  observations  upon  which  their 
deductions  have  been  based.  The  conclu- 
sions drawn  from  them  do  not  seem  war- 
ranted either  by  the  number  of  their  observa- 
tions or  the  conditions  under  which  they 
were  made.  •*  For  instance,  one  author 
studied  only  a  single  child;  another's  obser- 
vations were  made  almost  entirely  upon  his 
own  children;  a  third  based  his  conclusions 
upon  observations  of  three  children  two  of 
w^hom  were  quite  exceptional,  being  much 
over  weight ;  while  a  fourth  made  his  studies 
upon  children  who  were  inmates  of  an  in- 
stitution, most  of  them  under  weight.  Yet 
these  observ^ations  are  quoted  over  and  over 
again  in  textbooks  and  periodical  literature 
and  have  been  made  the  basis  of  very  broad 
and  widely  accepted  deductions. 

It  is  evident  to  all  who  study  this  subject 
that  even  in  normal  healthy  children  there 
are  very  considerable  indi\ddual  variations 


POOD   REQUIREMENTS  49 

in  food  requirements.  In  abnormal  children, 
especially  when  obsei'ved  under  unusual  con- 
ditions, these  variations  are  of  course  much 
greater. 

The  Different  Factors. — In  estimating  the 
total  caloric  requirements  all  the  different 
factors  which  go  to  make  up  this  total  must 
be  taken  into  account.  •These  are  essentially  tobeoon*-" 
four:  the  requirements  for  basal  metabo- 
lism, the  needs  for  growth,  the  needs  for  mus- 
cular activity  and  finally  the  food  values  lost 
in  the  excreta.  Unless  all  these  factors  are 
considered,  serious  errors  will  be  made  in  our 
estimates. 

The  first  of  these,  the  basal  requirement, 
is  fairly  uniform  for  children  of  the  same 
weight.  The  second,  the  growth  requirement, 
differs  at  different  periods  of  childhood.  The 
proportion  of  the  food  required  for  growth 
is  naturally  greatest  at  the  periods  when 
growth  is  most  rapid,  viz.,  during  the  first 
two  years  and  during  adolescence.  Growth 
variations  are  fairly  uniform  with  all  healthy 
children.  When  we  come  to  consider  the 
third  requirement,  the  needs  for  muscular 
activity,  we  find  great  variations  with  indi- 
vidual children  ;  but  in  general,  activity  tends 
to  increase  steadily  with  ago.  The  fourth  fac- 
tor, the  caloric  value  of  the  foodstuff  lost  in 


50  FOOD,    HEALTH  AND   GROWTH 

the  excreta,  appears  to  be  subject  to  very 
narrow  variations  with  healthy  children  of 
the  same  age,  unless  there  are  very  marked 
differences  in  the  diet. 

Basal  Metabolism. — Regarding  basal  re- 
quirements, that  is,  the  needs  of  the  body  at 
complete  rest,  a  great  deal  of  accurate  in- 
of  the  Body  lormation  has  been  accumulated  during  re- 
a^omp  •  e  ^^^^  years.  This  has  been  obtained  by  calori- 
metric  observations,  made  in  this  country 
chiefly  by  Benedict  and  Talbot,  DuBois  and 
Murlin,  and  abroad  by  Rubner,  Magnus-Levy, 
Heubner  and  others.  The  greatest  number  of 
observations  have  been  made  upon  adults, 
both  in  health  and  disease,  and  upon  infants. 
The  intervening  period  from  the  end  of  the 
first  year  to  the  completion  of  gro'«i;h  has 
not  been  so  generally  investigated.  Benedict 
and  Talbot  are  the  only  observers  who  have 
studied  systematically  this  entire  period ;  they 
have  recently  published  the  results  of  about 
250  observations  made  upon  children  of  both 
sexes,  more  than  half  of  whom  were  over 
one  year  of  age. 

The  range  of  individual  variation  in  the 
values  obtained  was,  as  might  be  expected, 
considerable.  Yet  the  number  of  observa- 
tions made  is  so  large  that  the  data  seem  suffi- 
cient to  warrant  us  in  accepting  their  results, 


POOD  REQUIREMENTS  51 

as  representing  the  average  for  the  period 
of  growth.    They  have  sho\sTi  that  the  basal 
metabolism  per  kilo,  of  body  weight  is  low 
in  the  newly-born  infant  and  that  it  rises  rap- 
idly until  about  nine  months  when  the  weight 
of  eight  or  nine  kilos,  is  reached.    After  that 
it  slowly  diminishes  up  to  adult  life.    They 
found   some   differences   between   the  basal 
needs  of  boys  and  girls.    After  a  weight  of 
10  kilos. — about  one  year — is  reached,  the  Jfo/toSkfiy 
basal  requirement  of  boys  exceeds  that  of  girls  J  of^at^t' 
until  a  weight  of  about  35  kilos,  is  reached,  KintMontn. 
at  about  eleven  years,  when  the  basal  needs 
of  girls  for  a  time  are  greater. 

The  total  basal  requirement  increases  with 
age,  but  the  relationship  is  best  expressed  as 
calories  per  unit  of  body  weight,  or  of  body 
surface.  In  the  opinion  of  Benedict  and  Tal- 
bot there  were  no  important  differences  be- 
tween caloric  values  expressed  per  unit  of 
body  surface  and  per  unit  of  body  weight. 
In  our  discussion  therefore  we  shall  use  the 
unit  of  body  weight  as  it  is  simpler  and  more 
convenient. 

The  observations  of  others  made  upon  a 
smaller  number  of  children  have  yielded  re- 
sults somewhat  higher  than  those  of  Benedict 
and  Talbot.  After  comparing  all  their  fig- 
ures, however,  it  seems  reasonable  to  accept 


52 


POOD,    HEALTH  AND   GROWTH 


What  la 
KMd»d  for 
Orovtli 


mil  Oreat- 

Mt    wh«D 

Orowtb  is 
Moit  Bftpld 


the  values  for  basal  requirement  given  by 
Benedict  and  Talbot  as  representing  what 
they  have  termed  *  *  the  irreducible  minimum ' ' 
which  must  be  supplied  to  the  human  organ- 
ism for  maintenance. 

Growth  Requirements. — In  considering  the 
food  requirements  which  must  be  suppUed  for 
growth,  special  growth  needs,  such  as  vita- 
mines  or  proteins  which  furnish  the  essen- 
tial amino-acids,  etc.,  will  not  now  be  dis- 
cussed, but  only  the  energy  requirements  for 
gro^\i;h  which  are  met  by  the  fat,  carbohy- 
drate and  protein  furnished  in  the  ordinary 
articles  of  food. 

What  is  required  for  growth  must,  it  is 
obvious,  be  greatest  when  growth  is  most 
rapid  and  diminish  when  growth  is  slower. 
How  the  growth  rate  diminishes  during  the 
early  years  and  increases  in  the  later  years 
of  childhood  may  be  expressed  by  the  annual 
increase  in  weight  and  height  from  birth  up 
to  the  time  when  the  body  reaches  its  mature 
size.  This  average  annual  increase  in  weight 
and  height  is  shown  for  both  sexes  in  the  ac- 
companying chart  (Fig.  3).  If  we  combine 
the  curve  representing  the  annual  increase 
in  weight,  and  that  for  the  annual  increase  in 
height  we  obtain  a  curve  which  may  be  taken 
to  represent  approximately  the  annual  in- 


Boys 


GIR15 


2345  6  769101iei314i5]6IT18-Year5  i  £34  5  6789101112131415)5118 


Fig.  3. — The  heavy  black  verticals  of  the  two  upper  charts  show  the 
annual  gain  in  weight  in  kiloa.  and  pounds,  and  the  gain  in  height  in 
centimetres  and  inches,  for  both  sexes.  The  lowest  charts  Bhow  values 
obtained  by  combining  the  two. 

53 


54  FOOD,   HEALTH  AND  OBOWTH 

crease  in  the  size  of  the  body  during  the  pe- 
riod of  growth.  This  rate  falls  rapidly  after 
the  first  year,  but  rises  again  after  the  tenth 
year  in  both  sexes,  reaching  its  maximum  in 
boys  at  the  sixteenth  and  in  girls  at  the  thir- 
teenth year  when  the  rate  is  nearly  twice  as 
great  as  at  ten  years. 

In  calculating  the  total  caloric  require- 
ments of  the  child  in  the  past,  it  appears  that 
sufficient  consideration  has  not  been  given  to 
these  variations  in  the  rate  of  growth.  The 
increase  in  the  body's  needs  for  growth  which 
must  be  supplied  by  the  food  is  not  uniform 
as  age  advances  from  early  childhood 
through  the  period  of  adolescence. 

If  we  use  as  a  basis  for  our  calculation  the 
annual  increase  in  weight,  it  is  possible  to  es- 
cSortMr      timate  approximately  the  number  of  calories 
orowtto         needed  for  growth  by  a  child  at  any  given 
age  and  weight.    Rubner  estimates  that  about 
80  calories   a  day   are  needed  to   increase 
the  weight  of  the  body  one  kilo,  in  one  year. 
If  we  multiply  this  value  by  the  average  in- 
crease in  kilos,  per  annum  it  would  give  ap- 
proximately the  number  of  calories  needed 
daily  at  that  age  for  growth.     Thus  a  boy 
.     between  the  ages  of  four  and  eleven  years 
I     who    gains    approximately    2^4    kilos.     (5 
pounds)  a  year  would  require  on  the  basis 


Estimated 


POOD  REQUIREMENTS  66 

of  Rubner's  calculation  an  average  of  nearly 
200  calories  a  day  for  normal  growth. 

During  the  sixteenth  year,  when  the  aver- 
age gain  in  weight  is  6.5  kilos,  (about  14 
pounds)  there  would  be  needed  for  growth 
alone  about  500  calories  a  day.  After  this 
time  the  growth  requirement  rapidly  falls 
and  when  growth  is  completed,  usually  in 
the  eighteenth  year,  it  of  course  ceases  en- 
tirely. We  have  found  it  impossible  to  verify 
in  the  laboratory  the  correctness  of  Rubner's 
method  of  estimating  the  caloric  needs  for 
growth,  but  clinical  observations  lead  us  to 
the  opinion  that  his  estimate  gives  results 
which  are  very  nearly  correct. 

Requirements  for  Activity. — ^When  we 
come  to  consider  the  caloric  allowance  which 
should  be  made  for  muscular  activity  we  SSS'for 
meet  the  greatest  practical  difficulty.  It  is 
hard  to  estimate  even  approximately  how 
many  calories  should  be  provided.  Allow- 
ance must  be  made  for  all  activity,  whether 
productive  or  unproductive.  Even  the  energy 
expended  in  the  process  of  digestion  must  be 
taken  into  account.  Benedict  states  that  the 
energy  needed  to  digest  the  food  taken,  uses 
up  about  6  per  cent  of  the  total  calories  of  the 
diet.  This  he  terms  the  *'cost  of  digestion." 
Like  the  food  value  lost  in  the  excreta  it  is 


ActlTlty 


56  FOOD,    HEALTH   AND   GROWTH 

one  of  the  inevitable  losses,  and  one  for  which 
allowance  must  be  made  in  estimating  the 
total  caloric  requirement  of  the  child. 

The  requirements  of  individual  children  for 
activity  differ  very  greatly,  more  widely  than 
they  do  in  any  other  respect.  A  nervous, 
SiMrra**'*  lively,  energetic  child  will  use  up  many  more 
Pood  ""  calories  in  activity  than  one  of  quiet,  placid 
temperament  and  indolent  muscular  habits. 
How  great  the  difference  is  between  the  act- 
ual needs  of  these  two  types  we  can  with  our 
present  knowledge  only  conjecture. 

Lusk  has  estimated  that  during  the  period 
from  four  to  fifteen  years  the  very  active 
child  requires  more  than  double  the  total  cal- 
ories of  a  quiet  child.  Since  three  of  the  four 
factors  which  make  up  the  total,  namely, 
basal  requirement,  growth  requirement  and 
the  food  value  lost  in  the  excreta,  are  nearly 
the  same  for  those  two  t^^pes  of  children,  it 
would  appear  that  practically  all  of  the  in- 
creased allowance  which  he  proposes,  or  con- 
siderably more  than  half  the  total  food  taken, 
is  used  up  by  the  very  active  child  in  muscular 
activity.  For  young  children  this  seems  ex- 
cessive. It  certainly  cannot  be  taken  as  an 
average. 

The  restriction  of  activity  to  conserve 
health  and  promote  growth  when  food  supply 


POOD   REQUIREMENTS  57 

is  insuflBcient  is  both  intelligent  and  scientific. 
We  are  told  by  Leonard  Hill  that  many  AcfmS* 
mothers  in  Germany  when  the  food  shortage  arowui 
was  greatest  were  accustomed  to  keep  their 
children  in  bed  the  greater  part  of  the  day, 
not  allomng  them  to  get  up  until  eleven 
and  putting  them  to  bed  at  four  o'clock. 

In  general,  a  progressive  increase  in  the 
calories  which  are  needed  for  activity  must  be 
allowed  as  age  advances.  As  soon  as  a  child 
has  learned  to  walk  a  great  increase  in  ac- 
tivity takes  place,  and  loss  of  weight  occurs 
when  no  increase  is  made  in  the  amount  of 
food  given,  sometimes  even  in  spite  of  it. 
The  loss  of  the  baby  fat  with  the  increase  of 
activity  which  is  seen  in  the  third  and  fourth 
years  is  a  familiar  fact.  With  the  normal  ; 
healthy  child  activity  increases  pretty 
steadily  with  each  year  up  to  the  period  of 
adolescence. 

DuBois  estimates  that  a  man  walking  at  a 
moderate  pace  on  the  level  uses  per  hour 
about  three  times  his  basal  caloric  require- 
ment. On  this  basis,  a  boy  of  30  kilos,  caiories 
weight,  or  about  ten  years  of  age,  w^alking  Moderat* 
on  the  level  for  two  hours,  would  require 
about  270  calories  to  supply  the  energy  for 
this  amount  of  acti\^ty.  But  such  exercise 
would  represent  a  small  part  of  the  energy 


How  »  Olilld 


58  POOD,   HEALTH  AND  GROWTH 

expended  in  a^day  by  an  average  healthy  boy 
of  ten. 

The  great  difference  in  food  requirements 
of  children  because  of  the  difference  in  their 
activity  is  not  in  most  cases  sufficiently  taken 
into  account  in  providing  their  diet.  If  the 
increased  caloric  need  of  the  active  child  is 
not  supplied  by  the  food,  growth  inevitably 
suffers. 

A  child's  food  intake  may  be  considered  his 
physical  income.  Out  of  this  certain  over- 
Sriocom.  head  expenses  must  always  be  met  first. 
These  are,  the  needs  of  basal  metaboUsm,  the 
normal,  necessary  activity  of  life,  and  the 
loss  in  excreta.  What  remains  may  be  spent, 
i.e.,  used  up  in  excessive  activity  or  saved, 
i.e.,  utilised  for  growth.  Both  of  these  he 
cannot  do.  Excessive  activity  is  always  at 
the  expense  of  weight  and  growth  unless  the 
food  intake  is  proportionally  increased. 
Every  physician  and  parent  knows  how  diffi- 
cult it  is  to  make  the  nervous,  energetic,  active 
child  put  on  weight,  even  with  the  usual  food 
intake  and  with  a  normal  digestion. 

Loss  in  Excreta. — No  accurate  observa- 
tions on  the  food  values  lost  in  the  excreta 
have  been  published  regarding  children  over 
six  years  of  age.  Our  own  studies  lead  us  to 
the  opinion  that  this  factor  varies  less  with 


Sxcr«ta 


POOD   REQUIREMENTS  59 

age  than  do  the  other  three  factors  which 
make  up  the  total  food  requirement  and  that 
in  health  the  loss  of  calories  is  equal  to  about 
10  per  cent  of  the  food  intake  for  children 
of  all  ages  after  infancy. 

Extensive  work  done  by  the  Department  of 
Agriculture  on  the  diet  of  adults  has  estab-  lom  m 
lished  quite  definitely  that  the  loss  in  the 
excreta,  when  a  mixed  diet  is  taken,  averages 
about  9  per  cent  of  the  total  calories  in- 
gested. Atwater  and  Sherman,  who  followed 
the  metabolism  of  three  six-day  bicycle  riders, 
found  an  average  loss  in  the  excreta  of  9  per 
cent  of  the  total  calories  taken. 

The  most  exact  observations  upon  children 
past  infancy  as  to  the  loss  in  excreta  have 
been  made  by  Miiller  who  studied  thirty-two 
children  from  two  to  six  years  of  age.  In 
order  to  determine  the  exact  food  value  lost, 
he  dried  the  stool  and  urine  of  each  child  as 
well  as  a  sample  of  the  composite  food  of 
each  and  determined  the  exact  caloric  value 
of  these  substances  by  burning  samples  in 
a  calorimeter.  His  estimation  of  the  loss  in 
the  urine  was  calculated  on  the  basis  of  its 
nitrogen  content.  His  calculation  gave  an 
average  total  daily  loss  in  the  excreta  of 
10.5  calories  per  kilo,  which  was  almost  ex- 
actly 10  per  cent  of  the  intake. 


60 


FOOD,    HEALTH  AND   GROWTH 


About  10 
Per  0«nt  of 
Food  Taken 
Lost 


Total 

Calories 
Bequired 
Estimated 
by  Body 
Welgbt 


In  our  own  observations  we  have  found 
that  healthy  children  under  six  taking  a  mixed 
diet  have  from  10  to  20  grams  of  dried 
matter  in  the  daily  stools.  Using  as  a  basis 
for  calculation  Miiller's  average  figure  for 
the  caloric  value  of  the  dried  stool,  and  also 
his  method  of  estimating  the  loss  in  the  urine, 
we  have  found  the  combined  loss  in  urine  and 
faces  by  healthy  children  from  one  to  six 
years  of  age  to  be  approximately  10  per  cent 
of  the  calories  usually  given  at  the  ages  men- 
tioned. 

The  loss  through  the  excreta  in  children 
with  disturbed  digestion  is  much  greater  than 
this,  and  is  of  practical  importance.  We  have 
found  the  loss  in  mild  forms  of  chronic  intes- 
tinal indigestion  to  reach  25  per  cent  of  the 
total  calories  taken.  The  estimate  of  10  per 
cent  of  the  calories  for  loss  in  the  excreta 
seems  therefore  a  reasonable  average  allow- 
ance for  normal  children  taking  a  mixed  diet. 

Total  Calories  Needed. — Having  consid- 
ered the  four  factors,  let  us  now  take  up  the 
question  of  the  total  calories,  estimated  ac- 
cording to  body  weight,  or  the  calories  per 
kilo.  Not  much  work  has  been  done  in  the 
determination  of  the  caloric  intake  of  chil- 
dren past  the  age  of  one  year.  In  1917  Gillett 
was  able  to  collect  from  literature  only  143 


FOOD   REQT'IREMENTS  61 

cases,  and  these  were  from  eighteen  authors, 
most  of  them  German,  in  which  this  calcula- 
tion had  been  made.  The  number  of  observa- 
tions made  by  each  author  was  small,  and  in 
several  cases  neither  the  condition  of  the  chil- 
dren nor  their  environment  was  such  as  to 
permit  us  to  draw  general  conclusions.  The 
observations  made  have  brought  out  many  in- 
teresting facts,  but  they  are  not  sufficient  to 
warrant  deductions  as  to  the  needs  of  the 
average  child. 

For  instance,  two  over-weight  girls  of  nine 
and  eleven  years,  studied  by  one  author,  took 
only  65  and  61  calories  per  kilo.  Of  throe  ^i^uons^' 
over-weight  girls  of  eleven,  thirteen  and  fif- 
teen years,  studied  by  another,  none  took 
more  than  45  calories  per  kilo;  while  some 
under-weight  boys  from  two  to  six  years  old 
took  an  average  of  113  calories  per  kilo. 

Camerer  studied  his  own  five  eliildron,  four 
girls  and  one  boy,  for  a  period  of  years.  In 
his  observations  made  when  the  children  were 
below  seven  years  old,  the  results  were  about 
those  generally  accepted  as  average  for  the 
period.  At  a  later  period  when  the  cliildren 
were  much  older  their  intake  was  vei-y  low. 
At  the  age  of  fifteen  it  was  only  a  httle  above 
the  needs  for  basal  metal)olisni  as  given  by 
Benedict  and  Talbot.    This  is  in  spite  of  the 


62  FOOD,   HEALTH  AND  GROWTH 

fact  that  the  children  were  considerably  be- 
low average  weight;  one  cannot  resist  the 
conclusion  that  they  were  under  weight  be- 
cause they  were  under  fed.  Yet  Camerer's 
results  have  been  more  widely  quoted  and 
used  as  a  basis  of  feeding  than  those  of 
almost  any  other  author. 

The  great  individual  variation  in  the  total 
food  intake  of  children  is  brought  out  by  the 
observations  of  Tigerstedt,  who  found  for 
example  that  the  intake  of  nine  children  in 
the  twelfth  year  ranged  from  44  to  89  calo- 
ries per  kilo.  Since  the  weights  of  the  chil- 
dren are  not  given  it  is  somewhat  difficult 
to  interpret  these  wide  variations. 

One  of  the  most  interesting  and  significant 
contributions  to  this  subject  is  that  of  Gep- 
»t8t.pjui;8  hart,  w^ho  made  observations  upon  the  boys  at 
St.  Paul's  School  at  Concord,  New  Hamp- 
shire. The  school  contained  about  360  boys 
whose  ages  ranged  from  twelve  to  seventeen 
years. 

The  method  he  employed  was  quite  differ- 
ent from  that  of  most  of  the  German  observ- 
ers, and  is  the  one  which  has  been  employed 
in  studying  the  food  consumed  by  soldiers  in 
the  army  camps.  It  seems  a  reliable  method 
of  determining  the  average  intake  of  large 
groups. 


School  Took 


FOOD  REQUIREMENTS 


68 


Gephart  first  calculated  the  caloric  value 
of  all  the  food  purchased  during  the  period 
of  observation,  which  was  the  entire  school 
year.  From  this  he  subtracted  the  values  ob- 
tained by  analysing  at  various  times  the  gar- 
bage and  the  waste.  The  remainder  he  di- 
vided by  the  total  number  of  meals  served, 
and  thus  obtained  an  average  caloric  value 
per  meal  for  the  school. 

In  addition  to  the  meals  which  were  pro- 
vided by  the  school,  the  boys  were  accus- 
tomed to  buy  from  a  confectioner's  shop  con- 
trolled by  the  school,  considerable  extra  food, 
chiefly  sweets — chocolate,  cakes,  etc.  The 
total  amount  purchased  there  during  the  pe- 
riod was  kno\\Ti,  and  was  apportioned  by  Gep- 
hart among  the  boys  of  the  whole  school.  The 
calorics  furnished  by  this  additional  food 
were  found  to  amount  to  about  one-eighth  of 
the  total  food  consumed. 


Table  2 — Summary  of  Gephart 's  Observations  ok  Boys 
AT  St.  Paul's  School 


.\vorag'e 
Age  in 
Years 

Average 

Weight 

Average  Calories  per 
Kilo. 

Average 
Total 
Daily 

Calories 

School 

Kilos 

Pounds 

School 

FVk)(1 
Shop 

Total 

Lower    .... 

Middle 

Upper 

13.5 
14.5 
16.1 

43.6 

50.8 
60.6 

96 
112 
133 

98 
88 
71 

15 
13 
11 

113 

101 
82 

4949 
5126 
4997 

64 


FOOD,    HEALTH  AND   GROWTH 


An  Active 
Growing 
Boy  Needs 
Much  Food 


The  average  daily  caloric  intake  was  found 
to  be  about  5000  calories  per  boy ;  and  all  but 
the  group  of  the  oldest  boys  took  over  100 
calories  per  kilo. 

WTiile  the  conclusions  which  might  be 
drawn  from  these  observations  may  perhaps 
be  open  to  some  question,  still,  the  results 
show  what  amount  of  food  is  actually  taken 
by  the  average  American  school  boy  at  the 
ages  studied,  under  the  special  conditions  rep- 
resented by  these  observations.  It  is  true 
that  these  conditions  were  somewhat  excep- 
tional. The  boys  were  living  in  a  rigourous 
chmate;  they  were  taking  much  out-of-door 
exercise  and  they  were  at  an  age  when  growth 
is  most  rapid. 

Furthermore,  the  well-known  disposition  of 
boys  of  these  ages,  when  not  restricted,  to 
eat  apparently  beyond  their  actual  needs 
must  also  be  taken  into  account.  Still,  when 
due  allowance  has  been  made  for  all  these 
conditions,  the  fact  remains  that  the  enor- 
mous appetites  of  active,  growing  boys  of 
the  ages  of  those  Gepharl  studied,  represents 
a  physiological  need,  which  in  the  past  has 
not  been  given  sufficient  consideration. 

Studies  made  on  such  large  groups  are 
likely,  we  believe,  to  give  results  much  nearer 
the  truth  than  obsen'ations  made  on  a  few 


POOD  REQUIREMENTS  65 

individnals  or  the  children  of  one  family,  no 
matter  how  carefully  such  observations  have 
been  made.  The  results  of  the  German 
studies  to  which  we  have  referred  would  lead 
one  to  allow  too  little  food  for  children  dur- 
ing the  active  growing  period.  From  obser- 
vation of  the  food  habits  of  the  average  Ger- 
man one  is  inclined  to  believe  that  this  de- 
ficiency is  quite  made  up  later  in  life. 

The  Department  of  Agriculture  has  made 
many  observations  on  the  amount  of  food 
taken  by  families,  including  children,  but  has 
not  determined  what  proportion  of  the  food 
was  taken  by  each  child.  They  have  appor- 
tioned the  diets  theoretically  according  to  a 
commonly  used  system  of  coefficients ;  for  ex- 
ample, assuming  that  if  a  man  takes  one  por- 
tion, a  woman  takes  0.8,  a  boy  of  twelve  takes 
0.8,  a  boy  of  eight  takes  0.7,  etc.  This  method 
of  calculation  is  open  to  serious  objections. 

Proposed  Schedules  of  Calories  per  Kilo. 

Several  of  the  authors  to  whom  we  have 
already  referred  have  proposed  complete 
schedules  of  caloric  requirements  per  kilo, 
from  infancy  to  adult  life. 

Among  the  German  authors,  Camerer's 
schedule  has  been  most  often  quoted  as  a 
standard.    His  allowance  for  boys  is  89  calo- 


66  FOOD,    HEALTH  AND   GROWTH 

ries  per  kilo,  at  the  age  of  one  year,  this  di- 
minishing to  75  calories  at  four  years.  After 
five  years  the  per  kilo,  allowance  rapidly  and 
steadily  decreases  to  adult  life.  His  values 
after  six  years  are  low,  w^hile  after  the 
twelfth  year  his  allowance  is  below  50  calo- 
ries per  kilo.  As  Benedict  and  Talbot  have 
found  the  basal  requirements  at  this  age  to 
be  nearly  40,  only  10  calories  per  kilo,  are 
left  for  growth,  activity  and  loss  in  excreta. 

Steffen  offers  a  schedule  for  children  up 
to  six  years  of  age  in  which  he  allows  over 
100  calories  per  kilo,  through  this  entire 
period. 

Uffelmann  has  proposed  a  schedule  for  the 
first  five  years  of  life.  His  values  are  lower, 
ranging  from  88  calories  per  kilo,  at  one  year 
to  68  at  five  years. 

Gillett  and  Sherman  from  the  published  ob- 
servations which  they  have  collected  have 
presented  a  table  of  values  for  total  daily 
calories  for  children  of  both  sexes  through- 
out the  entire  period  of  growth.  Their  aver- 
age allowance  for  bovs  diminishes  gradually 
from  95  at  one  year  to  68  calories  per  kilo,  at 
nine  years  and  is  kept  at  about  that  figure 
up  to  the  age  of  fourteen.  After  this  age  the 
average  allowance  is  rapidly  decreased  to 
55  calories  per  kilo,  at  sixteen  years.    Such 


POOD  REQUIREMENTS  67  ^ 

a  decrease  in  calories  per  kilo,  during  the 
period  of  most  rapid  growth  seems  unmse. 

Lusk  has  proposed  total  calories  per  kilo, 
for  three  types  of  children :  one  for  the  quiet 
child,  one  for  the  active,  and  one  for  the  very 
active  child.  His  values  for  the  very  active 
child  are  about  twice  those  for  the  quiet  Sff^encta 
child,  quite  irrespective  of  age  or  weight.  Ac-  w  AcuJity 
cordingly,  his  estimates  for  the  calories  for 
the  active  and  for  the  very  active  child  are 
extremely  high  for  the  early  years,  amounting 
respectively  to  129  and  193  calories  per  kilo, 
for  a  boy  of  two  years.  The  fall  in  calories 
per  kilo,  with  increasing  years  is  very  rapid 
for  all  his  groups.  His  values  for  the  quiet 
child  after  the  age  of  thirteen  are  very  little 
above  the  requirements  for  basal  metabolism 
and  normal  growth,  leaving  practically  noth- 
ing for  activity.  This  of  course  can  never  be 
reduced  to  zero. 

Fewer  authors  have  given  schedules  for 
girls.  In  those  of  Gillett  and  Sherman  and 
also  of  Camorer  the  allowance  is  consider- 
ably lower  than  that  for  boys;  after  the 
twelfth  year  that  given  is  only  a  very  little 
more  than  the  needs  for  basal  metabolism 
and  growth.    It  is  certainly  quite  inadequate. 

In  the  light  of  our  o^v^l  observations  and 
from  a  study  of  those  of  others,  theoretical 


Calories  per  kilo  for  Doljs 

ftjunds 

6411    2.2  33  44   55  66  77  "68  99   110  121   132        150 


Cobries 


I   Cabncs' 


Kilos  3.5     10 1  pi  120!  2^  30j  ^  140  i  45  li)  55  [  6D   65  f/O 
Yeans       12  345678  9101112  13   14     15      16  1718       Adult 


Pounds 
a§_ll    22 

Cabnes 


Cabries  per  Kilo  for  qirls 


Kilos  3.5 

Years 

Fig.  4. — The  solid  vertical  lines  indicate  weights  in  kilos;  the  broken 
lines,  approximate  weights  at  each  year  of  age.  The  space  between 
lines  AA  and  BB  shows  allowance  for  basal  metabolism;  between  BB 
and  CC,  that  for  growth;  between  CC  and  DD,  that  for  muscular  ac- 
tivity; between  DD  and  EE,  food  values  lost  in  excreta.  The  space 
between  the  lines  AA  and  EE  shows  the  total  caloric  allowance  per 
kilo. 

Fig.  5. — The  vertical  and  curved  lines  have  the  same  significance  as 
in  Fig.  4, 

68 


FOOD  REQUIREMENTS  69 

schedules  indicating  average  calories  per  kilo, 
of  body  weight  have  been  calculated  for  both  ^^^^^ 
sexes  and  are  sho\vn  in  Figures  4  and  5,  p»rKiio. 
indicating  the  total  calories  per  kilo,  for  dif- 
ferent weights  for  approximate  ages,  also 
the  proportion  of  the  total  which  is  allowed 
for  each  of  the  different  factors  which  have 
been  considered. 

It  will  be  observed  that  the  basal  require- 
ment per  kilo.,  adopting  that  of  Benedict  and 
Talbot,  reaches  its  maximum  at  about  the 
ninth  month,  after  which  it  falls  steadily 
throughout  the  entire  period  of  growth  to 
adult  life. 

The  calories  allowed  per  kilo,  for  growth 
fall  steadily  from  the  first  to  the  sixth  year, 
remain  practically  constant  up  to  eleven  years 
for  girls  and  thirteen  years  for  boys,  when 
a  marked  increase  takes  place 

This  increased  need  is  evident  for  about 
three  years  with  both  sexes,  after  which  the 
growth  needs  rapidly  diminish  to  zero. 

The  needs  for  basal  metabolism  and  for 
growth  though  subject  to  considerable  indi- 
vidual variation  are  as  averages  practically 
irreducible. 

In  the  absence  of  definite  data  upon  many 
points  what  should  bo  allowed  for  activity  is 
admittedly  hj-pothetical.     For  reasons  pre- 


70 


FOOD,    HEALTH   AND   GROWTH 


viously  discussed  this  has  been  increased 
steadily  from  the  second  to  the  thirteenth 
year  for  boys  and  to  the  twelfth  for  girls. 
Whether  the  allowance  for  activity  should  be 
further  increased  during  the  period  of  most 
rapid  growth  is  somewhat  doubtful.  It  is 
a  matter  of  common  observation  that  while 
the  body  is  increasing  so  rapidly  in  size  as 
it  does  at  this  time  there  is  not  infrequently 
seen  in  both  sexes  a  growing  disinclination 
to  active  muscular  exertion,  which  is  usually 
accompanied  by  a  corresponding  disinclina- 
tion to  mental  activity.  For  these  reasons  no 
increase  in  the  caloric  allowance  per  kilo,  for 
activity  has  been  made  during  these  years 
of  most  active  growth ;  possibly  even  a  sUght 
reduction  should  be  considered. 

The  number  of  calories  we  have  allowed 
for  loss  in  the  excreta  after  the  first  year  of 
life  is  10  per  cent  of  the  total. 

With  the  values  proposed  for  the  different 
factors  just  discussed,  the  total  calories  per 
kilo,  are  for  both  sexes  about  100  at  one  year, 
falling  to  93  calories  per  kilo,  at  two  years, 
and  to  80  at  six  years.  This  value  we  have 
continued  for  boys  up  to  about  the  sixteenth 
year.  For  girls  the  calories  per  kilo,  have 
been  slightly  increased  during  the  eleventh 
year,  since  there  is  at  this  time  an  increased 


FOOD  REQUIREMENTS  71 

growth  need  and  since  the  basal  needs  for 
this  and  the  next  few  years  are  nearly  uni- 
form. After  the  sixteenth  year  in  boys  and 
the  fourteenth  year  in  girls,  the  total  calories 
per  kilo,  have  been  rapidly  reduced  to  adult  JJ^j^cft 
standard — about  48  for  males  and  44  for  fe- 
males— since  there  is  a  rapid  decline  in 
growth  needs  and  possibly  some  reduction  in 
activity. 

The  chief  differences  between  this  schedule 
for  total  calories  per  kilo,  and  others  which 
have  been  proposed  is  that  the  per  kilo,  al- 
lowance is  nearly  uniform  from  the  age 
of  six  to  the  end  of  the  period  of  rapid 
growth. 

In  the  practical  appUcation  of  these  sug- 
gested values  it  must  be  borne  in  mind  that 
each  component  part  of  the  caloric  require- 
ment is  subject  to  considerable  individual 
variation.  The  curve  suggested  aims  only 
to  give  averages.  Activity  is  of  course  the 
most  obvious  variant.  An  extremely  active 
child  will  undoubtedly  utilise  more  calories 
than  the  average  which  we  have  allowed, 
while  the  needs  of  a  quiet  child  may  be  sup- 
plied by  somewhat  less  than  the  allowance 
made. 

Another  cause  for  variation  in  the  caloric  "' 
requirement  for  the  individual  is  the  relation 


72  POOD,   HEALTH  AND   GROWTH 

of  weight  to  height  and  age.  All  observations 
show  that  the  under-weight  child  vnW  take 
and  will  utilise  more  calories  per  kilo,  than 
the  child  of  average  weight;  while,  as  might 
bo  expected,  one  who  is  over  weight  does  not 
take  and  docs  not  need  the  average  number 
of  calories  per  kilo.  These  facts  must  always 
be  taken  into  account  in  the  caloric  allowance 
for  an  individual  child.  The  average,  how- 
ever, is  not  quite  the  same  as  the  normal. 

An  allowance  of  from  5  to  10  calories 
per  kilo,  both  above  and  below  the  average 
allowance  may  be  considered  a  normal  range. 
AVhen  activity  is  excessive,  however,  an  in- 
crease of  20  or  even  30  calories  per  kilo, 
above  the  average  may  be  well  utihsed. 

Camcrer's  schedule  gives  very  little  al- 
lowance for  acti\dty  except  between  the  ages 
of  four  and  eight  and  after  the  age  of  thir- 
teen years  practically  none  at  all. 

The  curve  based  on  the  average  values  of- 
fered by  Gillett  and  Sherman  does  not  differ 
greatly  from  the  one  here  proposed  up  to  the 
age  of  seven  years.  From  seven  to  fourteen 
years  it  is  nearly  parallel  ^^'ith  it,  but  is  some- 
what lower.  After  fourteen  years  their  curve 
falls  rapidly.  The  allowance  they  have  made 
both  for  activity  and  for  growth  during  ado- 
lescence seems  much  too  small. 


POOD  REQIHREMENTS  73 

Total  Daily  Calories. — Thus  far  only  the 
calories  per  kilo,  of  body  weight  have  been 
considered.  In  Figure  6  and  Figure  7 
are  given  the  curves  which  show  the  total 
daily  calories  allowed  for  healthy  children 
of  average,  normal  weights  at  the  different 
ages,  using  the  values  above  suggested.  They 
also  show  for  the  different  years  the  propor- 
tion of  the  separate  factors  which  make  up 
the  total,  viz.,  basal  needs,  growth  needs,  al- 
lowance for  activity  and  for  loss  in  the  ex- 
creta. 

The  daily  calories  allowed  for  both  boys 
and  girls  are  about  950  at  one  year.  The  in- 
crease with  succeeding  years  is  a  little  more  caiories 

Needed  at 

rapid  for  boys  than  for  the  girls  until  the  age  5*^^"°' 
of  twelve  is  reached.    From  twelve  to  four- 
teen the  total  calories  for  the  girls  exceed 
those  for  boys. 

After  fourteen  the  allowance  for  boys  is 
considerably  greater  than  that  for  girls.  The 
highest  values  for  daily  calorics  are  3330  for 
girls  at  the  age  of  fourteen  and  4100  for  boys 
at  the  age  of  sixteen.  After  these  maximum 
figures  are  reached  the  values  drop  very  rap- 
idly to  adult  standards  for  moderate  activity 
— about  2640  for  women  and  3360  for  men.^ 

^  Since  this  lecture  was  writtcu  some  Knfjlish  fifjures  on 
the    metabolism    of    adolescents    have    been    published    hy 


Ages 


Cabnei  Total  dailu  calories  for  bous 

5000 


4000 
3000 
2000 
1000 


>fear5     1    23456789K)ni213l4l5»nBB20 

Fig.  6. — The  distance  between  the  base  and  the  upper  line  shows  the 
allowance  for  total  daily  calories  according  to  age,  from  birth  to 
adult  life.  The  spaces  between  the  various  lines,  from  the  base  line 
upward,  indicate  the  allowance  for  the  different  factors  which  make 
up  the  total,  namely,  for  basal  requirement,  growth,  actlTity  and  loss 
in  excreta. 


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Years     1    234    56789  10.  11I2  13M15I6  17I8B20 


Fig.  7. — The  curved  lines  and  spaces  have  the  same  significance  aa  in 
Fig.  6. 


74 


FOOD  BEQUIREMENTS  75 

These  charts  show  the  provision  which 
must  be  made  for  the  growth  needs  during 
the  period  of  adolescence.  The  maximum 
growth  need,  calculated  according  to  Rub- 
ner's  formula  previously  referred  to,  for  girls 
amounts  to  380  calories  daily  during  the  thir- 
teenth vear  and  for  boys  to  about  500  calo-  orowta 
ries  daily  during  the  sixteenth  year.  This 
represents  about  14  per  cent  of  the  food  in- 
take. This  greatly  increased  need  for  nor- 
mal growth  at  this  period  has  not  been  suf- 
ficiently taken  into  account  by  most  authors 
in  estimating  the  total  daily  calories  required. 

The  large  allowance  for  activity  is  of 
course  the  most  debatable  factor  in  the  esti- 
mate presented.  Some  may  think  this  allow- 
ance excessive  but  the  more  recent  observa- 
tions, particularly  those  of  Gephart,  seem  to 
justify  the  position  taken.  The  total  daily 
caloric  allowance  for  boys  of  the  age  of 
those  studied  by  Gephart  is  still  much  bo- 
low  the  calorics  which  he  found  to  be  actually 
taken  by  the  St.  Paul  boys  observed  by  him. 
However,  as  previously  stated,  these  boys 
were  no  doubt  living  under  rather  exceptional 

Wright.  Ilis  obsorvations  wore  niado  upon  boys  in  training 
Bliijis.  The  niininuiiii  daily  intake  reconiuiondcd  at  thirteen 
and  fourteen  years  is  .'5800  cah)ries  and  fift<H>n  and  sixteen 
years  4100  calories,  which  corresponds  very  strikingly  with 
the  allowance  hero  suggested. 


76 


FOOD,    HEALTH   AND   GROWTH 


An  Ado- 
lescent Boy 
or  Girl 
Needs  More 
Food  than 
a  Man  or 
Woman 


conditions  and  the  calories  that  were  taken 
by  them  can  hardly  be  used  as  a  basis  for 
estimating  normal  averages. 

According  to  the  schedule  presented,  the 
allowance  for  acti\aty  varies  from  6  per  cent 
of  the  total  calories  during  the  first  year  to 
a  maximum  of  44  per  cent  of  the  total  calories 
during  the  period  of  adolescence.  This  does 
not  seem  excessive  for  this  active  period. 

It  is  a  common  observation  and  undoubt- 
edly a  true  one,  that  during  adolescence  the 
average  boy  or  girl  takes  more  food  than  the 
average  adult  man  or  woman.  Unquestion- 
ably this  is  proper  and  represents  a  real 
physiological  need.  It  is  only  by  assuming 
such  values  for  calories  per  kilo,  as  have  been 
proposed  that  one  can  reach  a  total  daily 
caloric  intake  which  will  be  in  accord  with 
these  conditions. 

Other  authors  who  have  given  complete 
schedules  for  food  requirements  have  all 
steadily  increased  the  total  daily  calories  ^^'ith 
age  through  childhood  and  adolescence  up  to 
the  standard  allowance  for  adults.  No  one 
has  proposed  a  schedule  according  to  which 
the  values  for  total  daily  calories  during  ado- 
lescence exceed  adult  standards  and  fall  to 
adult  standards  with  the  completion  of 
gro^vth.     This  seems  to  be  absolutely  neces- 


POOD   REQUIREMENTS  77 

sary;  for  unless  this  is  done,  the  increasing 
gro'VNi;h  needs  must  be  deducted  from  the  al- 
lowance for  activity,  leaving  for  the  latter  a 
very  small  remainder ;  or,  on  the  other  hand, 
if  activity  is  maintained,  gro^vth  must  suffer,  excmsit© 
The  modem  child,  boy  or  girl,  is  usually  an  ^•"Expense 
active  person  during  adolescence.  If  in  **'  °"^'*^ 
school,  he  is  required  by  school  routine  to  take 
systematic  exercise.  If  he  has  left  school 
and  gone  to  work,  he  is  required  continually 
to  expend  a  good  deal  of  physical  energy.  In 
view  of  these  facts  it  is  quite  evident  that 
the  food  taken  by  probably  the  majority  of 
boys  and  girls  of  the  class  which  leaves 
school  at  fourteen  or  fifteen  years  and  enters 
industry  during  this  period  of  rapid  growth, 
is  totally  inadequate. 

After  completing  our  theoretical  schedule 
for  total  food  requirements  w^e  have  endeav- 
oured to  test  its  accuracy  by  a  study  of  the 
number  of  calories  that  healthy  children  hv- 
ing  under  good  conditions  actually  took  in 
their  usual  diet.  In  other  words,  having  de- 
termined what  children  should  take  to  meet 
the  separate  needs  as  we  had  calculated  them, 
we  next  proceeded  to  find  out  if  what  might 
be  considered  normal  healthy  children  did 
take  anything  like  such  an  amount  of  food. 
This  proved  no  easy  task.    As  already  stated, 


78 


rOOD,    HEALTH   AND   GROWTH 


Wkftt 

HMUtiir 

▲ntrlcaa 
ClilldrNi 
ITsuaUy 
T&k* 


of  Baek 
CklJd  f»r 
Four  Con- 
Mcntir* 
Dayi 


the  observations  upon  such  children  reported 
in  literature  have  been  few  in  number. 

We  have  at  present  collected  over  one  hun- 
dred individual  diet  records  of  children  from 
one  to  sixteen  years  of  age — a  suflficient  num- 
ber to  warrant  some  conclusions.  They  were 
selected  children;  chosen  because  they  were 
healthy,  well  cared  for  and  normal  as  to  di- 
gestion. Almost  all  were  children  in  private 
families,  living  in  excellent  surroundings. 
The  parents  were  nearly  all  well-educated, 
interested  in  the  purpose  of  our  experiment, 
and  willing  to  cooperate.  Our  aim  was  to 
learn  what  such  children,  fed,  it  was  believed, 
intelligently,  actually  took  in  their  accus- 
tomed diet,  vdih  the  belief  that  the  diet  they 
"were  receiving  was  fairly  t\'pical  of  what  is 
usually  taken  by  well  American  children. 
They  were  not  all  from  New  York  City.  A 
number  lived  in  the  su])urbs  and  some  were 
from  New  England  in  the  vicinity  of  Boston, 
so  that  the  diet  does  not  represent  the  ideas 
of  any  one  pliysician  or  group. 

A  report  of  the  net  weight,  height,  activity, 
appetite,  general  condition,  etc.  was  obtained, 
together  ^^^th  a  record  of  the  exact  amount 
of  each  separate  item  of  food  taken  by  the 
child  for  four  consecutive  days.  From  these 
data  the  caloric  value  of  the  average  daily 


FOOD  REQUIREMENTS  79 

diet  was  calculated.  Not  only  was  the  value 
for  the  total  calories  obtained,  but  also  the 
distribution  of  the  calories  as  fat,  carbo- 
hydrate and  protein,  which,  together  with 
other  facts  brought  out,  will  be  discussed  in 
the  next  lecture.  We  used  for  the  most 
part  established  caloric  values  of  the  com- 
mon articles  of  food  compiled  by  Locke.  The 
values  of  a  number  of  articles  were  calculated 
from  the  results  of  analyses  made  in  our  own 
laboratory. 

This  method  of  estimating  the  calories 
taken  by  children  is  of  course  not  absolutely 
accurate,  but  it  undoubtedly  gives  a  very  close 
approximation.  While  there  are  slight  vari- 
ations from  the  usual  caloric  values  of  the 
food  taken,  owing  to  differences  in  the  meth- 
ods of  preparation,  it  is  probable  that  these 
errors  tend  to  balance  each  other  and  that 
they  do  not  materially  affect  the  net  result. 
We  feel  certain  that  in  no  case  did  the  child  ^t^/^ 
receive  less  food  than  was  reported.  It  is 
not  unlikely  that  in  some  cases  a  child  actu- 
ally took  more  than  was  reported,  especially 
some  of  the  older  children  whose  diet  is  not 
so  carefully  superv^ised  and  who  are  more 
likely  to  eat  between  meals  wdthout  the  knowl- 
edge of  the  parent.  Tf  there  is,  tliercfore, 
an  appreciable  error  in  the  estimation  it  is 


80 


FOOD,    HEALTH   AND   GROWTH 


Explanation 
of  Some 
Wide  Va- 
riations 


that  the  calculated  amount  is  low  rather  than 
high. 

The  largest  number  of  the  records  were  of 
children  under  eleven  years  of  age.  There 
are  from  five  to  twelve  observations  for  each 
year  up  to  the  age  of  eleven.  Beyond  this  age 
the  number  of  observations  for  each  year  is 
too  small  to  warrant  definite  conclusions,  yet 
the  results  are  interesting. 

In  Figure  8  are  shown  the  total  calories 
taken  daily  by  each  of  these  children  ar- 
ranged according  to  age.  The  curves  shown 
are  those  based  upon  the  schedules  proposed 
for  average  daily  calories  at  different  ages, 
which  have  already  been  discussed.  The 
curve  for  boys  is  indicated  by  the  solid 
line ;  that  for  girls,  by  the  broken  line.  The 
individual  observations  for  boys  are  shown 
by  the  large  dots;  those  for  girls,  by  small 
circles. 

This  chart  shows,  as  was  to  be  expected,  a 
considerable  variation  in  individual  obsei'\'^a- 
tions.  However,  for  the  most  part  they  fall 
near  the  curves ;  and  up  to  the  age  of  eleven 
the  average  falls  verj^  near  the  curves.  Be- 
yond that  age  there  are  as  yet  too  few  ob- 
servations to  be  conclusive.  However,  those 
made  on  older  boys  are  very  close  to  the  pro- 
posed cur^^e. 


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Snimary 


82  FOOD,   HEALTH   AND   GROWTH 

Some  of  the  observations  which  vary  most 
widely  from  the  average  curve  deserve  special 
mention.  There  were  eight  children  whose 
total  calories  taken  amounted  to  over  one- 
third  more  than  the  theoretical  average  re- 
quirement; but  every  one  of  these  children 
was  reported  to  be  exceedingly  active.  There 
were  only  two  children  whose  total  calories 
were  more  than  one-third  less  than  the  theo- 
retical average  requirement,  but  these  girls 
were  both  very  large  for  their  ages,  in  fact, 
had  nearly  attained  adult  stature  and  accord- 
ingly did  not  need  the  number  of  calories  for 
growth  usual  for  that  age. 

On  the  whole,  it  would  seem  that  the  curves 
suggested  are  approximately  correct  for  the 
average  caloric  requirements  up  to  the  age 
of  eleven  years.  We  feel  confident  that  a 
larger  number  of  observations  for  the  late^ 
years  will  verify  the  estimates  for  those  years 
also. 

To  sum  up  our  discussion  to  this  point,  it 
is  clear  that  in  calculating  the  total  caloric 
requirements  of  children  there  must  be  con- 
sidered separately  the  component  parts  of 
which  the  total  is  made  up,  namely,  the  re- 
quirements for  basal  metabolism,  for  g^o^vth, 
for  muscular  activity  and  food  values  lost  in 
the  excreta. 


FOOD  EEQUIBEMENTS  8S 

The  great  differences  in  the  calculations  of 
different  writers  who  have  estimated  theo- 
retical values  for  total  calories  per  kilo,  for 
children,  are  in  part  due  to  the  fact  that  they 
have  not  sufficiently  considered  the  compo- 
nent parts  which  make  up  the  total. 

The  basal  requirements  per  kilo,  are  high- 
est at  about  nine  months  and  steadily  fall 
from  this  time  up  to  adult  life. 

The  food  value  normally  lost  in  the  excreta 
is  a  nearly  uniform  proportion  of  the  intake, 
about  10  per  cent,  for  all  ages  after  infancy. 

The  requirements  for  growth  are  greatest 
during  the  period  when  growth  is  most  active, 
namely,  during  the  first  years  of  life  and  dur- 
ing adolescence.  From  the  fourth  to  the  tenth 
or  eleventh  year  they  are  nearly  uniform. 

The  average  for  three  factors — basal, 
gro^vth  requirements  and  food  values  lost  in 
excreta — are  nearly  uniform  for  healthy  chil- 
dren of  the  same  weight  living  under  similar 
conditions.  The  requirement  for  activity  is 
the  only  factor  which  varies  widely  with  dif- 
ferent individuals. 

The  average  caloric  requirement  of  chil- 
dren is  about  100  calories  per  kilo  at  an  age  ATera«e 
of  one  year.     For  boys  it  falls  to  about  80  iB«nt» 
calories  at  six  years  and  remains  practically 
constant  at  this  value  up  to  the  age  of  fifteen 


84 


POOD,    HEALTH   AND   GROWTH 


years  as  the  increasing  requirements  for  ac- 
tivity are  offset  by  the  reduction  in  basal  re- 
quirements. After  a  weight  of  50  kilos,  (about 
fifteen  years)  is  reached  the  calories  per  kilo. 


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FOOD  BEQUIREMENTS  85 

can  rapidly  be  reduced  to  adult  standards, 
about  48  calories  per  kilo.  The  requirement 
for  girls  falls  to  76  calories  per  kilo,  at 
about  six  years  and  continues  near  this  value 
until  growth  is  complete,  then  falls  rapidly 
to  adult  standards,  about  44  calories  per  kilo. 

In  this  calculation  there  have  been  allowed 
considerably  more  calories  per  kilo,  during 
adolescence  than  have  been  recommended  by 
others.  This  seems  to  be  necessary  because 
of  the  increased  growth  needs  at  this  time 
and  the  large  requirement  for  muscular  ac- 
tivity. 

According  to  our  allowance  the  total  daily 
caloric  requirement  of  children  of  both  sexes 
during  adolescence  exceeds  by  nearly  1000 
calories  the  requirements  of  the  adult  man 
or  woman  of  moderate  activity. 

Children  who  are  under  weight  require 
more  and  those  who  are  over  weight  fewei* 
calories  per  kilo,  than  those  who  are  of  aver- 
age weight  for  their  age. 

The  schedule  here  proposed  is  a  tentative 
one  and  is  based  on  present  knowledge  which 
is  in  many  respects  incomplete.  There  are 
a  number  of  points  which  must  be  studied 
more  fully  before  definite  standards  can  be 
established. 

The  practical  value  of  such  a  standard  is 


SUndard 


86  FOOD,   HEALTH  AND   GROWTH 

that  it  represents  a  normal  average.  Such 
A"?i»"  an  average  is  of  course  not  to  be  rigidly  ap- 
plied to  every  individual  child.  Still  an  aver- 
age standard  is  useful;  mth  this  one  may 
compare  the  diet  of  individual  children  who 
may  not  be  thriving  and  also  it  may  be  used 
as  a  guide  in  providing  for  large  groups  of 
children  in  asylums,  homes  or  large  boarding 
schools,  although  perhaps  it  is  less  important 
than  other  factors  in  the  diet  to  be  considered 
later. 


CHAPTER  III 

Lecture  Three 
I.    Protein  Bequirement 

In  the  previous  lecture  the  total  caloric 
requirement  throughout  the  entire  period  of 
growth  was  discussed.  In  the  present  one 
we  shall  consider  somewhat  in  detail  the 
different  conditions  which  influence  or  which 
determine  the  amount  of  each  of  the  impor- 
tant constituents  of  the  child 's  diet, — the  pro- 
tein, fat  and  carbohydrate. 

All  three  of  these  nutritive  substances  are 
sources  of  energy  *  and  may  be  utilised  as 
such  in  the  body.  There  are,  however,  other 
important  considerations  which  affect  the 
amount  of  each  one  of  them  in  the  diet.  Es- 
pecially is  this  true  of  the  protein.  Before 
considering  the  other  food  elements  it  is  de- 
sirable to  establish  first  the  protein  require- 
ment. 

•  Energy  as  applied  to  food  may  be  expressed  in  term«  ol 
heat  or  mechanical  work;  it  may  bo  usod  up  immediately 
or  stored  in  the  body  for  future  use. 

87 


88 


FOOD,   HEAX.TH  AND  GROWTH 


Proteins 

Ar*  Very 

Complex 

SnbBtances 

and  Hato 

Different 

Valaes 


The  proteins  are  indispensable  to  life;  no 
other  foods  can  supply  the  nitrogen  which  is 
necessary  for  the  constant  renewal  of  the  cells 
of  the  body.  They  are  very  complex  sub- 
stances, being  composed  of  some  sixteen  or 
eighteen  different  amino-acids.  These  araino- 
acids  are  sometimes  called  the  building  stones 
of  the  body.  The  proteins  differ  very  much  in 
their  value  as  foods,  according  to  the  amount 
of  the  particular  amino-acids  of  which  they 
are  made  up.  So  that  it  is  impossible  to  con- 
sider how  much  protein  is  needed  during  the 
growi:h  period  unless  we  also  take  into  ac- 
count the  kind  of  protein  which  is  given. 

In  the  process  of  digestion  the  proteins  of 
the  food  are  split  up  in  the  intestines  into 
their  various  amino-acids.  These  are  ab- 
sorbed and  subsequently  recombined  to  form 
the  proteins  of  the  body.  Now  the  pro- 
portions of  amino-acids  in  the  body  proteins 
are  not  the  same  as  in  the  food  proteins.  It 
follows  therefore  that  not  all  the  amino-acids 
of  the  food  are  utilised  in  building  up  the 
body  structure  or  in  making  the  repairs  which 
the  wear  and  tear  of  every  day  makes  neces- 
sary. Those  amino-acids  which  are  not  util- 
ised in  this  way  as  building  materials  are 
used  largely  for  energy,  being  broken  down 
into  urea  and  excreted  in  the  urine. 


PROTEIN   REQUIREMENT  89 

The  food  proteins  differ  greatly  in  the 
amino-acids  they  contain;  they  may,  there- 
fore, furnish  a  considerable  excess  of  one  or  SSiiS'w 
more  of  those  needed  as  building  materials,  ]^rar^ 
while  at  the  same  time  they  may  be  deficient  iunouLt 
in  others  which  are  quite  as  necessary.    Cer- 
tain of  the  amino-acids  such  as  leucin,  gluta- 
mic acid,  arginin,  prolin  and  others,  which 
form   a  large  proportion   of  the  body  pro- 
teins, are  present  in  abundance  in  practi- 
cally all  the   proteins   of  the   food;   conse- 
quently an  ample  supply  of  these  is  always 
assured. 

But  there  are  other  amino-acids  especially 
needed  for  growth,  such  as  lysin,  cystin  and 
tryptophan,  which  are  found  in  much  smaller 
amounts,  and  in  Avidely  varying  proportions 
in  the  different  food  proteins.  Many  of  the 
food  proteins  are  in  fact  entirely  wanting  in 
one  or  other  of  these  particular  amino-acids. 
Hence,  special  care  must  be  taken  to  provide 
in  the  diet  of  gro^ving  children  either  those 
proteins  having  the  larger  proportions  of 
these  important  amino-acids,  or  if  the  pro- 
teins which  have  the  smaller  proportions  of 
these  substances  are  given,  they  must  be  fur- 
nished in  the  diet  in  greatly  increased  amount. 
It  is  obvious,  therefore,  that  the  total  protein- 
requirement  for  children  during  the  period 


90  FOOD,   HEALTH   AND  GROWTH 

of  growth  is  to  a  great  extent  dependent  on 
the  kind  of  the  protein  given. 

It  is  well  known  that  the  animal  proteins 
resemble  the  proteins  of  the  human  body- 
more  nearly  than  do  those  of  vegetable  origin ; 
for  this  reason  they  are  definitely  preferable 
during  the  period  of  growth.  For  the  child, 
therefore,  the  animal  proteins,  such  as  are 
furnished  in  milk,  eggs  and  meat,  are  dis- 
tinctly of  a  higher  grade  than  the  vegetable 
proteins.  With  our  present  knowledge  it 
seems  necessary,  if  vegetable  proteins  are 
depended  upon  in  the  diet  of  children,  to  sup- 
ply them  in  larger  amounts  than  when  animal 
proteins  are  given  and  even  then  we  may  not 
secure  normal  growi;h. 

In  estimating  the  child's  protein  need  there 
are  two  distinct  functions  of  protein  which 
must  be  considered.  The  first  is  the  require- 
ment for  tissue  repair  and  general  mainte- 
nance ;  the  second  is  that  needed  for  growth. 
In  adult  life  the  first  need  is  the  only  one 
which  has  to  be  supplied.  In  childhood  the 
second  is  quite  as  important. 

Even  the  protein  requirement  of  the  adult 
has  been  the  subject  of  much  controversy.  It 
has  been  found  possible  to  maintain  nitrogen 
equilibrium,  or  a  balance  between  intake  and 
excretion,  in  an  adult  man  or  woman  on  a 


PROTEIN  REQUIREMENT  91 

protein  intake  as  low  as  40  grams  daily.  J^VmJu 
There  are  some  writers  who  believe  that  this  "'^*'»i*" 
minimum  allowance  is  a  sufficient  supply. 
The  average  adult  dietary,  however,  furnishes 
very  much  more  than  this ;  as  compiled  from 
many  sources  it  allows  from  100  to  120  grams 
of  protein  daily.  This  amount,  which  may  be 
considered  as  an  expression  of  human  experi- 
ence, has  been  regarded  by  many  as  the  opti- 
mum protein  need.  This  amount  of  protein 
allows  an  average  of  about  1.4  grams  of  pro- 
tein per  kilo,  of  body  weight. 

Sherman,  who  has  recently  investigated  the 
average  protein  intake  of  over  100  adults, 
found  the  average  minimum  to  be  44.4  grams 
per  day.  This  represents  about  0.6  gram 
per  kilo,  for  a  person  of  average  weight.  His 
conclusion  is  that  for  an  adult  1.0  gram  of 
protein  per  kilo,  is  quite  enough  for  main- 
tenance. 

The  question  has  been  much  debated 
whether  this  maintenance  need  can  be  en-  .„,„.,_ 

Animal  ti. 

tirely  supplied  by  vegetable  proteins.  The  Ji^^^* 
work  of  a  number  of  investigators  indicates 
that  this  is  possible.  Shennan,  however,  be- 
lieves that  better  results  are  obtained  by  sup- 
plying part  even  of  the  maintenance  require- 
ment by  animal  protein.  Among  the  vege- 
table proteins  there  are  certain  ones,  notably 


92  FOOD,    HEALTH   AND   GROWTH 

zein,  a  protein  of  com,  which  are  insufficient 
even  for  maintenance. 

From  w^hat  we  know  of  the  adult  protein 
need  it  may  reasonably  be  inferred  that  the 
gro\^dng  child  with  his  more  active  metabo- 
lism requires  for  maintenance  from  1.0  to  1.5 
grams  per  kilo,  of  body  weight  daily.  It 
seems  probable  that  this  can  be  supplied 
either  from  vegetable  or  from  animal 
sources. 

In  addition  to  the  maintenance  need,  how- 
ever, the  child  must  be  supplied  with  a  gener- 
ous allowance  of  protein  for  growth.  Because 
the  vegetable  proteins  as  a  group  are  so  poor 
in  certain  of  the  important  amino-acids,  it 
seems  necessary  to  supply  the  protein  needed 
for  growth  by  animal  protein.  It  is  quite  pos- 
sible then  that  an  adult  might  be  kept  in  per- 
fect health  upon  a  vegetarian  diet;  but  it 
is  extremely  doubtful  whether  such  a  diet  for 
a  child  would  insure  normal  growth.  How 
much  protein  should  be  furnished  to  cover 
the  growth  requirement  it  is  difficult  to  esti- 
mate. 

No  experimental  work  has  been  reported  on 
the  protein  need  of  children  and  the  effect 
on  their  growth  of  either  a  very  low  or  a  very 
generous  protein  intake.    Osborne  and  Men- 


PROTEIN   REQUIREMENT  93 

del  have  been  able  to  obtain  very  definite 
quantitative  results  on  protein  needs  in  their  SKreS 
work  with  rats.    These  are  not  only  interest-  orowtn' "° 

of  lUta 


PtOTCIRS    RtlRFORCED   BY  ADDITION  OFAMIRO  ACIDS. 


iniiiMNVn   Win  U.IMII 


Fig.  9. — This  chart  shows  that  the  amino-afid  lysin  is  in- 
dispensable for  growth.  It  is  taken  from  Osborne  and 
Mendel  and  shows  the  effect  upon  the  growth  of  rats  of  add- 
ing lysin  to  and  witlulrawing  it  from  the  diet. 

In  the  first  part  of  the  upper  curve  the  protein  given  is 
composed  of  equal  parts  of  zein,  a  protein  of  corn,  and 
gliadin,  a  protein  of  wheat.  Zein  is  one  of  the  poorest 
proteins  and  animals  cannot  be  maintained  upon  it  when 
it  is  the  only  protein  in  the  food;  it  contains  no  lysin;  glia- 
din has  only  a  very  small  amount  of  lysin.  In  the  second 
part  of  the  upper  curve,  when  all  the  protein  is  furnished 
by  gliadin,  a  slight  growth  is  observed;  but  when  lysin  is 
added  an  immediate  growth  begins  which  persists  (dotted 
line)   at  a  rate  exceeding  the  normal  increase  (solid  line). 

In  the  first  part  of  the  lower  curve  the  protein  is  gliadin. 
When  lysin  is  added  there  is  a  quick  growth  resjjonse  which 
ceasea  when  the  lysin  is  omitt(Hl,  is  rcsumetl  by  its  addition 
and  again  stops  when  the  lysin  is  withdrawn. 


94  FOOD,    HEALTH   AND   GROWTH 

ing  in  themselves  but  have  an  important  bear- 
ing upon  the  protein  needs  of  children.  They 
have  determined  exactly  how  much  of  certain 
proteins  are  required  to  support  normal 
growth  in  rats;  also,  what  is  especially  sig- 
nificant, to  what  extent  the  amount  of  these 
proteins  in  the  diet  can  be  reduced  if  their 
quality  is  improved  by  the  addition  of  amino- 
acids  in  which  they  are  known  to  be  deficient ; 
thus  how  rapid  growth  can  be  secured  with 
certain  low  grade  proteins  when  these  are 
reinforced  by  the  addition  of  certain  amino- 
acids  (Figs.  9  and  10). 

Such  experimentation  is  by  its  very  nature 
quite  impossible  with  children.  Accordingly, 
about  the  only  guide  which  we  have  to  a 
knowledge  of  the  total  protein  need  for  chil- 
dren is  to  be  found  in  a  study  of  the  actual 
amounts  of  protein  which  are  taken  by  nor- 
mal, healthy  children  in  their  customarj^  diet. 
It  is  fully  realised  that  the  results  of  such 
a  method  of  investigation  as  this  are  not  con- 
clusive, but  they  are  strongly  suggestive. 

To  begin  with,  let  us  consider  the  nursing 
infant.  The  total  protein  intake  of  a  normal 
infant  at  the  breast  is  very  low.  Up  to  the 
age  of  eight  or  nine  months  the  amount  sel- 
dom exceeds  12  grams  daily ;  this  is  equivalent 
to  only  about  1.5  grams  per  kilo.  This  amount, 


PROTEIN  REQUIREMENT 


95 


it  is  to  be  remembered,  must  supply  not  only 
the  maintenance  requirement  but  the  need  for 
g/owth,  and  that  too  during  the  most  active 


MDTCINS  REINFORCED  BY  ADOmON  OF  AMINO-ICIOS 


■■■■UMmi    VITH 

CASEW 

•va 

1 

r i 

MO 

cmiHi 

/ 

aM 

«M 

— 

/ 

^ 

•• 

^ 

/ 

uo 

m 

•0 
40 

/ 

/ 

y 

^'• 

4t 

M 

/^ 

;^ 

1— 44M(»-J 

Fifj.  10. — In  this  chart  from  Osborne  and  Mendel  the 
upper  curve  shews  the  growth  of  rats  whose  food  contained 
18  per  cent  casein.  The  first  part  of  the  lower  curve  shows 
the  slower  growth  upon  9  per  cent  casein  and  the  effect  upon 
growth  of  adding  and  then  withdrawing  cystin.  Casein 
protein  is  notably  deficient  iu  cystin  and  a  larger  amount  of 
casein  must  bo  given  to  insure  normal  growth. 

period  of  growth  in  the  life  of  the  child,  as 
the  healthy  child  usually  doubles  his  weight 
in  the  first  five  months.    That  this  amount  is 


96 


FOOD,    HEALTH   AND   GROWTH 


sufficient  needs  no  argument.  We  find  our 
best  examples  of  good  nutrition  and  growth 
in  breast-fed  infants. 

The  reason  why  this  small  protein  intake 
does  supply  the  infant's  entire  requirements 
is  to  be  found  in  the  fact  that  the  protein  of 
woman's  milk  is  certainly  best  adapted  in 
its  amin6-acid  colhposition  for  digestion 
and  assimilatioh  by  the  infant  and  f6r  his 
growth.^ 

Now  when  cow's  milk  is  substituted  for 
woman's  milk  the  conditions  have  materially 
changed.  No  longer  will  infants  thrive  satis- 
factorily on  a  protein  intake  of  10  or  12  grams 
daily.  Experience  has  long  taught  us  that 
the  protein  intake  must  now  be  considerably 
increased" — doubled^  or  even  trebled.  Infants 
from  one  to  nine  months  of  age,  when  fed  on 
the  usual  modifications  of  cow's  milk,  receive 
from  3  to  4  grams  of  protein  per  kilo.  The 
great  increase  in  protein  requirement  when 
cow's  milk  is  substituted  for  woman's  milk  is 
probably  due  to  the  difference  between  the 
two  milks  in  the  amino-acids  which  their  pro- 
teins contain.  The  protein  of  woman's  milk 
is  protein  of  a  very  high  grade.  It  is  com- 
posed of  two-thirds  lactalbumin;  and  lactal- 
bumin  of  all  the  proteins  contains  the  high- 
est proportion  of  leucin,  lysin  and  trypto- 


PROTEIN   REQUIREMENT  97 

phan,  amino-acids  which  are  particularly  im- 
portant for  growth.  Woman 's  milk  contains 
about  twice  as  much  lactalbumin  as  does 
cow's  milk.  Casein,  which  forms  about  five- 
sixths  of  the  protein  of  cow's  milk,  is  of  com- 
paratively low  grade  as  a  growth  protein, 
being  notably  deficient  in  cystin.  In  order  to 
secure  an  adequate  supply  of  this  amino-acid 
a  greatly  increased  amount  of  casein  must 
therefore  be  taken. 

This  is  well  shown  by  Osborne  and  Men- 
del's experiments  upon  rats;  they  obtained 
good  growth  when  the  food  contained  18  per 
cent  of  casein;  poor  growth  with  9  per  cent, 
but  good  growth  with  9  per  cent  if  cystin  was 
added  (Fig.  10). 

The  failure  of  condensed  milk  as  a  food 
for  infants  has  been  ascribed  to  many  causes ;  r»unre.  in 
by  some,  to  its  low  fat  and  its  relatively  high  low  Pro- 
suga^  content ;  by  others,  to  the  effect  of  heat 
and  age  upon  its  vitamine  content.  With  the 
facts  just  mentioned  before  us  it  now  seems 
clear,  that  equally  important — ^perhaps  more 
important  than  either  of  these  considerations 
— is  its  low  i^rotcin.  In  the  dilutions  in  which 
this  is  usually  fed,  the  percenta2:e  of  protein 
ranges  from  1  to  1.4,  which  is  only  about  the 
amount  which  an  infant  taking  woman 's  milk 
receives. 


tttlna 


98 


FOOD,    HEALTH   AND   GROWTH 


Infants  B»- 
eelTe  Only 
Animal 
Proteins 


Again,  in  the  early  days  of  milk  modifica- 
tion by  the  percentage  method,  it  was  thought 
that  formulas  from  cow's  milk  in  which  the 
proportions  of  fat,  sugar  and  protein  were 
as  nearly  as  possible  the  same  as  those  found 
in  woman 's  milk,  w^ould  be  the  best  substitute 
for  it.  But  those  who  followed  this  plan  in 
practice,  were  doomed  to  disappointment. 
The  failures  from  the  use  of  such  formulas 
were  variously  explained ;  by  most,  they  were 
ascribed  to  the  too  high  fat,  and  no  doubt 
this  w^as  sometimes  the  case;  but  it  now 
seems  quite  evident  that  an  important  error 
w^as  the  low  protein  in  many  of  these  formulas. 
With  clinical  experience  it  has  become  in- 
creasingly clear  during  the  last  few  j'ears, 
that  the  majority  of  infants  ^ill  not  thrive 
normally  upon  cow's  milk  sinless  they  are 
given  two  or  three  times  as  much  protein  as 
is  contained  in  woman's  milk;  also  that  the 
higher  total  protein  of  cow's  milk  is  not  the 
principal  cause  of  its  difficult  digestion  by  the 
average  infant. 

The  proportion  of  vegetable  proteins  in 
the  diet  of  infants  is  a  very  small  one. 
Whether  nursed  or  artificially  fed  the  infant 
receives  practically  his  entire  protein  supply 
in  the  form  of  animal  protein,  at  least  dur- 
ing the  first  six  months  of  life.    It  is  only 


PROTEIN  REQUIREMENT  99 

when  cereal  additions  are  given,  either  as 
flour  incorporated  in  the  milk  formula  or  as 
cereal  given  separately,  that  a  portion,  al- 
though at  first  a  very  small  one,  of  the  pro- 
tein given  is  of  vegetable  origin. 

When  we  come  to  consider  the  diet  of  chil-  ^monnt  of 
dren  past  the  period  of  infancy,  we  find  that  mtnd™dfor 
almost  nor^  a'ttention  has  thus  far  been  paid  to  ciudren 
its  quantitative  composition.    There  is,  there- 
fore, very  little  material  to  be  found  in  the 
literature  concerning  the  actual  daily  amount 
of  protein  taken  by  older  children.    The  few 
scattered  data  which  have  been  published  are 
for  the  most  part  incidental  to  researches  on 
other  subjects.    Most  of  the  authors,  whose 
reports  on  the  total  calories  taken  by  chil- 
dren were  discussed  in  the  previous  lecture, 
have  also  reported  the  protein  content  of  the 
diets  taken. 

Gillett  has  compiled  from  eighteen  authors, 
145  cases  in  which  the  amount  of  protein 
taken  daily  is  given.  These  include  most  of 
the  values  for  protein  intake  published  in  the 
literature  up  to  1917.  Her  summary  shows 
that  the  average  protein  intake  of  all  the 
groups  was  at  least  2  grams  per  kilo,  and  the 
average  of  the  younger  children  3  grams  per 
kilo. 

Miiller  studied  the  diet  of  32  children  from 


100  FOOD,    HEALTH   AND   GROWTH 

two  to  six  years  of  age,  inmates  of  an  insti- 
tution, who  took  an  aveiiage  of  3.5  grams  of 
proteins  per  kilo,  daily.    It  should  be  borne 
in  mind,  however,  that  these  children  were 
much  under  weight.   "Me  thinks  that  the  pro- 
tein need  of  children  is  proportionally  very 
much  greater  than  that  of  adults,  and  that 
chudrcn's      uo  attempt  should  be  made  to  reduce  the  pro- 
oreltS    **  tein  intake  to  a  minimum,  lest  growth  be  in- 
Ad!ut8'         terfered    "SNith    and    general    nutrition    im- 
paired. 

Gephart  in  his  observations  on  the  adoles- 
cent boys  in  St.  Paul's  School  found  the  pro- 
tein intake  to  be  very  high  at  these  ages.  The 
average,  tota.1  daily  protein  was  about  160 
grams;  while  the  average  EXDteijj  per  kilo, 
ranged  from  2^6  to  3^  grams. 

■vCamerer  recommends  over  4  grams  of  pro- 
tein per  kilo,  for  the  first  year,  from  3  to  4 
up  to  the  eighth  year,  over  2  grams  until  the 
fourteenth  year,  diminishing  to  1.7  grams  at 
the  end  of  the  gro\\i:h  period. 

In  the  previous  lecture  were  presented  the 
values  for  total  calories  actually  taken  by 
over  one  hundred  healthy  children  from  one 
to  seventeen  years  of  age.  In  each  of  these 
cases  it  will  be  recalled  we  obtained  complete 
diet  records  for  a  period  of  four  days.  These 
children    were    from    intelligent,    well-to-do 


PROTEIN    REQUIREMENT 


101 


families  and  may  be  assumed  to  be  taking 
diets  which  are  fairly  representative  of  what 
children  under  such  circumstances  usually 
receive. 

A  study  of  the  amount  of  protein  taken  by  T^^^^y 
them  should,  therefore,  give  some  idea  of  the  Jm^rfcan 
usual  amount  in  the  diet  of  healthy  Ameiican  ^^"'^'^•^ 
children.      These    results    correspond    quite 
closely  mth  those  just  quoted,  except  that 


am 

Crama  Total  Protelr 

TnKen 

Dolly 

. 

re 

m 

BO 

zi 

Boys 
Cirto 

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^ 

^ 

-*-" 

^ 

• 

^ 

• 

u 

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■-5- 

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-_^ 

. 

•  . 

i 

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^~ 

10 
»5 

0 

;"  > 

> 

^ 

tS* 

:r^ 

-"S* 

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m 

• 

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r- 

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r 

Fig.  11. 


during  the  adolescent  period  of  rapid  <^rowth 
the  intake  was  the  greater,  and  diminished 
after    growth    was    slower    and    completed. 

Average  total  protein  in     2nd  and     3rd  yrs.  wiis     4!)  tir-ims  ;  4.0  per  kilo 

"  "  "         "      6tli   anil      7tli     "        "       M        •'         X.ii     "       " 

'*  "         '*  11th   and   ]2t!i    "        "       !ti)        "         2.8     "       " 

"         "  ir>th  and   16th    "        "     130        "        2.3     "      " 

"  "         "         "  IStli  year  "        "     11,".        "         2.0     "       " 

Our  observations  indicate  that  in  the  usual 


Exceptional 

Frotttin 

InUk* 


102  FOOD,   HEALTH   AND  GROWTH 

diet  approximately  15  per  cent  of  the  total 
calories  taken  by  children  over  one  year  old 
should  be  supplied  by  protein. 

In  Figure  11  is  given  the  total  daily  intake 
of  protein  of  the  individual  children.  The 
solid  and  dotted  lines  represent  for  boys  and 
girls  respectively  the  grams  of  protein  which 
are  equivalent  to  15  per  cent  of  the  calories 
recommended.  While  the  great  majority  of 
these  cases  fall  reasonably  near  the  average 
lines  there  are  some  interesting  exceptions 
which  are  worth  noting.  There  are  four 
young  girls  whose  protein  intake  was  very 
high.  All  were  extremely  active  children, 
in  excellent  health,  whose  total  food  intake 
was  very  high.  There  were  two  large  girls 
of  thirteen  and  one-half  years  and  fourteen 
years  who  took  a  very  low  amount  of  protein. 
But  both  had  attained  practically  their  full 
growth  and  for  them  really  the  only  protein 
need  was  that  for  maintenance. 

There  were  three  boys  about  ten  years  old 
with  very  high  intake.  The  explanation 
in  each  case  was  excessive  activity.  A  four- 
teen-year-old boy  taking  210  grams  of  protein 
daily  is  an  example  of  what  is  so  often  ob- 
served, that  is,  the  very  large  amount  of  food 
frequently  taken  by  an  active,  rapidly  grow- 
ing boy  at  this  age.    It  will  be  recalled  that 


PROTEIN   REQUIREMENT  103 

the  average  intake  of  the  St.  Paul's  School 
boys  was  about  160  grams  daily. 

The  grams  of  protein  per  kilo,  of  body  c^^^ 
weight  taken  by  these  children  agree  pretty  w^ght*' 
well  "v^ith  the  findings  which  have  been  pub- 
hshed  by  others.  Four-fifths  of  the  children 
observed  took  between  2.2  and  4.4  grams  pro- 
tein per  kilo.  The  average  was  4.4  per  kilo, 
for  the  youngest  group.  The  fourteen  who 
took  more  than  4.4  grams  per  kilo,  were 
mostly  young  and  very  active  children,  only 
three  being  as  much  as  five  years  of  age.  In 
general,  the  intake  per  kilo,  tended  to  dimin- 
ish as  age  advanced.  That  for  the  oldest 
group,  from  fourteen  to  seventeen  years,  was 
between  2  and  2i/2  grams  per  kilo. 

The  values  for  some  of  the  older  children, 
particularly  for  girls  between  twelve  and 
fifteen,  are  low;  but  it  is  probable  that  with 
more  data  the  average  of  these  years  would 
be  higher  than  is  shown  in  the  table  omug 
to  rapid  growth  at  this  age. 

These  observations  on  normal  children 
have  also  been  analysed  with  respect  to  the 
proportion  of  animal  and  vegetable  protein 
in  the  diets  taken. 

Most  of  the  children  took  over  60  per  cent 
of  their  total  protein  in  the  fonn  of  animal 
protein,   from  milk,   eggs,  meat,   etc.     The 


PEOTEIN  REQUIREMENT  105 

average  was  66  per  cent  of  the  total  protein 
from  animal  sources,  and  34  per  cent  vege-  ^^^u' 
table  protein.  Figure  12  shows  graphically  ATSnlf*'^'^'' 
the  percentage  division  of  the  total  protein  in 
the  diet  of  each  child.  The  values  are  ar- 
ranged in  order  of  age ;  there  was  no  constant 
variation  noted. 

That  there  was  found  so  little  variation  in 
the  proportion  of  animal  and  vegetable  pro- 
tein in  the  diet  of  the  different  children  was 
a  matter  of  much  surprise. 

These  observations  indicate  that  healthy 
children  in  their  usual  diet  take  about  4.0 
grams  of  protein  per  kilo,  at  the  age  of  one 
year,  the  amount  diminishing  to  about  2.5 
grams  per  kilo,  or  0.25  per  cent  of  body 
weight  at  six  years  of  age  and  remaining 
at  about  this  value  or  slightly  below  it  until 
the  end  of  growth,  and  that  of  this  total  prac- 
tically two-thirds  is  animal  protein.  This 
quantity  of  protein  may  perhaps  be  regarded 
at  present  as  the  optimum  and  may  therefore 
be  recommended  as  a  suitable  intake  for  the 
growing  child. 

When  we  come  to  consider  how  much  of  this 
total  should  be  animal  protein  we  have  very 
little  knowledge  to  guide  us.  It  is  quite  p)os- 
sible  that  children  might  do  well  if  less  than 
two-thirds  of  this  was  animal  protein.    How- 


106 


FOOD,    HEALTH  AND  GROWTH 


Vegetable 
ProUins  of 
Low*r 
Orad»  and 
Mor*  Moat 
b*  OlTan 


Bammary 


ever,  from  what  is  known  of  the  growth  prop- 
erties of  the  vegetable  proteins  as  a  class  it 
is  evident  that  a  much  larger  amount  of  vege- 
table protein  would  be  required  if  the  amino- 
acids  necessary  for  normal  growth  were  sup- 
plied. 

Vegetable  protein  cannot  replace  animal 
protein  gram  for  gram.  Accordingly,  if  one 
is  to  give  a  larger  proportion  of  vegetable 
protein  than  the  usual  one-third  of  the  total 
requirement,  it  seems  clear  that  the  total  pro- 
tein intake  must  be  considerably  increased. 
In  our  common  vegetable  foods  protein  is 
always  associated  with  carbohydrate  and 
when  the  amount  of  vegetable  protein  given 
is  increased  very  much  above  the  average,  it 
should  be  realised  that  the  amount  of  carbo- 
hydrate is  necessarily  increased  also,  and 
this  may  be  undesirable  and  may  be  a  cause 
of  disturbance  to  digestion. 

In  conclusion  it  is  evident  that  no  estimate 
of  the  amount  of  protein  required  for  the 
proper  nutrition  of  ohildreii  can  be  made 
without  taking  into  account  the  kind  of  pro- 
tein given,  since  the  amino-acid  content  of 
different  proteins  varies  so  considerably; 
also  that  in  estimating  the  protein  needs  of 
the  child  not  only  must  the  need  for  mainte- 
nance 1)0  supplied,  as  with  the  adult,  but  also 


FAT  REQUIREMENT  107 

a  liberal  amount  of  protein  must  be  allowed 
for  growth. 

The  fact  that  the  small  amount  of  protein, 
taken  by  nursing  infants  is  adequate  is  due 
to  the  superior  amino-acid  composition  of  the 
proteins  of  woman's  milk. 

When  cow 's  milk  is  substituted  for  woman 's 
milk  the  amount  of  protein  allowed  should  be 
increased — doubled  or  trebled. 

Vegetable  proteins  as  a  class  are  of  a  dis- 
tinctly lower  grade  than  animal  proteins,  and 
while  they  may  be  adequate  for  maintenance, 
with  our  present  knowledge,  it  is  hazardous 
to  depend  upon  them  for  growth. 

n.    Fat  Eequirement 

The  amount  of  fat  which  is  required  in  the 
diet  during  growth  has  not  yet  been,  and 
cannot  be  established  until  the  exact  role 
of  fat  has  been  determined.  Until  quite  re- 
cently it  has  been  generally  believed  that 
fat  did  not  play  any  specific  part  in  nutrition, 
but,  like  carbohydrate,  served  as  a  source  of 
energy  and  as  a  sparer  of  protein.  Because 
of  this  belief  very  little  attention  has  been 
given  to  the  amount  of  fat  which  is  desirable 
in  the  diet,  except  in  the  case  of  infants.  Re- 
cent investigations,  however,  have  shown  that 
fat  is  of  greater  importance  than  was  for- 


108 


FOOD,    HEALTH   AND   GROWTH 


merly  believed,  and  that  it  has  specific  func- 
tions in  nutrition  quite  apart  from  those 
which  it  shares  with  the  carbohydrates.  It 
has  been  sho^\Tl  that  during  growth  fat  is 
especially  important.  There  are  now  recog- 
nised to  be  several  reasons  for  regarding  fat 
as  a  necessary  constituent  of  the  diet  of  chil- 
dren. 

Fat  is  the  carrier  of  the  fat-soluble  vita- 
mine  which  has  been  proven  to  be  essential 
for  health  and  normal  growth.  A  fuller  dis- 
cussion of  this  will  be  taken  up  later  with  the 
general  subject  of  accessory  food  substances. 
How  much  of  this  vitamine  should  be  pro- 
vided for  the  child  is  not  yet  known. 

From  the  evidence  which  has  been  obtained 
it  would  seem  that  the  amount  of  fat  needed 
for  this  purpose  is  comparatively  small;  but 
in  order  to  insure  normal  growth  it  is  prob- 
ably wiser  to  supply  in  the  diet  a  generous 
amount  of  such  fats  as  are  known  to  contain 
this  substance. 

Among  the  usual  foodstuffs  the  richest 
sources  are  milk  fat,  egg  yolk  and  certain  ani- 
mal organs — liver,  kidney,  etc.  It  is  es- 
pecially abundant  in  cod  liver  oil.  This  vita- 
mine  is  also  found  in  the  green  leaves  used 
as  vegetables,  but  since  the  young  child  can 
take  only  a  comparatively  small  quantity  of 


PAT  REQUIREMENT  109 

these  in  the  diet  it  is  not  vnse  to  depend  upon 
them  as  a  source  of  this  vitamine  to  any  great 
extent. 

Since  the  function  of  the  vitamines  has 
been  appreciated  there  has  been  a  growing 
tendency  on  the  part  of  those  particularly 
interested  in  them  to  regard  the  fat  of  the 
diet  of  special  importance  only  as  a  carrier 
of  vitamine  A. 

These  investigators  seem  inclined  to  attrib- 
ute all  the  bad  effects  of  a  diet  low  in  fat 
to  a  vitamine  deficiency.  The  fact  that  such 
a  diet  predisposes  to  rickets  and  possibly  to 
oedema,  that  it  increases  the  susceptibility  to 
infection  and  retards  growth,  is  explained  by 
them  in  this  way.  Their  contention  is  that 
if  suflBcient  vitamine  A  is  supplied  in  a  diet 
which  is  fat-free  but  otherwise  adequate,  the 
conditions  just  mentioned  will  not  develop. 

Most  of  the  conclusions  regarding  the  func-  ■^^'Jj^f*' 
tions  of  vitamines  have  been  drawn  from  ex- 
periments upon  small  laboratoiy  animals, 
chiefly  rats.  Mendel  and  Osborne  have  re- 
cently published  the  results  of  experiments 
continued  for  from  four  to  eight  months  in 
which  they  obtained  what  they  considered 
normal  growth  in  rats  on  a  diet  in  which  the 
fat  was  extremely  low,  amounting  to  but  1/20 
of  one  per  cent  of  the  total  food ;  but  the  diet 


110  POOD,   HEALTH  AND  GROWTH 

included  the  necessary  amount  of  the  vita- 
mine  A,  derived  in  this  case  from  dried  al- 
falfa leaves.  They  conclude  that  '*if  true 
fats  are  essential  for  nutrition  during  growth 
the  minimum  necessary  must  be  exceedingly 
small. ' ' 

To  apply  too  dogmatically  to  human  beings 
the  results  of  experiments  upon  small  ani- 
mals which  are  of  a  species  so  different, 
seems  open  to  some  question.  The  natural 
diet  of  the  rat  is  very  unlike  that  of  human  be- 
ings and  consequently  its  digestive  processes 
may  not  be  entirely  comparable.  Hence,  it 
is  conceivable  that  fat  may  have  functions  in 
human  nutrition  which  may  not  be  required  of 
it  in  the  nutrition  of  the  rat,  quite  apart  from 
that  as  a  purveyor  of  vitamine  A. 

Von  Groer  of  Vienna  has  observed  the  ef- 
fects of  a  diet  practically  fat-free  upon  two 
infants  from  birth.  The  food  given  was  sepa- 
rated cow's  milk  containing  only  0.01  per  cent 
of  fat,  with  enough  cane  sugar  added  to  give 
a  total  carbohydrate  content  of  about  8.5  per 
cent.  This  diet  was  not  only  practically  de- 
void of  fat,  but  also  extremely  low  in  vita- 
mine  A  and  very  high  in  carbohydrate.  Both 
infants  gained  in  weight  \\T^th  fair  regularity 
for  six  months.  But  after  six  months  the 
gain  ceased.    Both  developed  rickets  and  were 


FAT  EEQUIREMENT  111 

very  susceptible  to  infection.  The  conclu- 
sions reached  by  von  Groer  is  that  for  at 
least  the  first  six  months  of  life  infants  can 
be  successfully  nourished  on  a  diet  which  is 
practically  fat-free  provided  the  calories 
needed  are  supplied  by  sugar.  His  reported 
results  hardly  bear  out  this  contention. 

Another  function  of  fat  which  is  questioned 
by  some  is  its  influence  on  mineral  metabo- 
lism. This  has  been  much  debated  and  the 
subject  cannot  yet  be  regarded  as  entirely 
settled.  Many  laboratory  observations  have 
been  made  to  ascertain  the  influence  of  the 
fat  intake  upon  the  mineral  metabolism  of 
infants  and  very  young  children. 

Unfortunately  the  results  thus  far  have 
been  conflicting  and  final  conclusions  have 
not  yet  been  reached.  Although  some  investi- 
gators are  convinced  that  there  is  no  rela- 
tion between  the  fat  intake  and  the  mineral 
metabolism  in  general,  we  feel  certain  that 
in  the  case  of  calcium  metabolism  at  least  a 
very  definite  relation  exists.  The  work  on  J^'g^^JoQ 
calcium  metabolism  done  in  the  Babies'  Hos-  <"  caicium 
pital  laboratory  indicates  that  the  best  cal- 
cium absorption  takes  place  when  the  fat  in 
the  diet  bears  a  certain  relation  to  the  cal- 
cium and  when  the  intake  of  both  is  liberal^ 
The  results  indicate  that  the  daily  fat  intake 


112  POOD,    HEALTH  AND   GROWTH 

of  children  from  two  to  four  years  of  age 
should  not  be  less  than  3.0  grams  per  kilo, 
to  insure  proper  absorption  of  calcium.  This 
requirement  seems  to  diminish  up  to  six  years 
of  age  to  about  2,0  grams  per  kilo.,  but  is 
probably  maintained  at  about  this  figure 
throughout  the  remainder  of  childhood. 
Since  adequate  absorption  of  calcium  is  nec- 
essary for  bone  growth,  this  need  seems  a 
very  important  one.  The  observations  also 
show  that  for  the  purpose  of  calcium  absorp- 
tion a  vegetable  fat  will  serve  quite  as  well  as 
an  animal  fat. 

Some  authors  have  recently  taken  the 
ground  that  the  fat  of  the  diet  has  an  impor- 
tant influence  on  the  metabolism  of  protein. 

It  is  contended  that  the  amount  of  fat  in 
the  diet  should  at  least  be  equal  to  the  amount 
of  the  protein.  Thus  fat  should  not  be  re- 
garded as  supplementary  to  the  dietary  re- 
quirement but  an  integral  part  of  it.  It  is 
certainly  a  very  significant  fact  that  in 
woman's  milk  the  fat  exists  in  a  considerably 
greater  amount  than  the  protein  while  in 
cow's  milk  they  are  nearly  equal. 

It  is  generally  accepted  that  the  lack  of  fat 
in  the  diet  increases  susceptibility  to  infec- 
tions, especially  to  tuberculosis.  Although 
children  may  apparently  do  very  well  for  a 


PAT  REQUIREMENT  113 

time  on  a  low  fat  or  a  fat-free  diet,  the  com- 
plete eUmdnation  of  fat  from  the  diet  or  even 
its  reduction  to  insignificant  proportions,  as 
recently  proposed  by  Pirquet,  seems  a  hazard- 
ous experiment. 

Furthermore,  it  seems  clear  that  a  reason- 
able amount  of  fat  in  the  diet  is  useful  in 
maintaining  normal  chemical  and  bacterio- 
logical conditions  in  the  intestine.  This  is 
indicated  by  observations  on  the  character 
and  composition  of  the  stools.  When  fats  are 
excluded  or  greatly  reduced  in  the  diet  there 
is  inevitably  a  great  increase  in  the  carbo- 
hydrates. Among  many  stools  studied  we 
have  not  found  any  which  would  be  generally 
regarded  as  typically  normal  in  character 
and  consistency  under  these  conditions.  With 
children  whose  digestion  is  normal  the  change 
does  not  take  place  at  once ;  but  after  a  period 
usually  of  a  week  or  ten  days  the  stools  gen- 
erally become  softer,  more  of  a  *' mushy"  con- 
sistency w^th  greatly  increased  acidity  and 
after  a  short  time  mucus  usually  appears. 
There  is  also  a  change  in  the  intestinal  flora. 
The  addition  of  fat  to  the  food  very  quickly 
brings  about  a  decided  improvement  in  the 
appearance  of  the  stool. 

Only  a  small  part,  usually  about  5  per  cent, 
of  the  ingested  fat  is  not  absorbed;  but  we 


Fat  In 
IntMtiiiM 


114  FOOD,    HEALTH  AND   GROWTH 

believe  that  this  amount  has,  as  Hutchison 
has  recently  suggested,  a  special  function  to 
perform,  and  is  not  to  be  regarded  as  a  pure 
excretion. 
Excreted  The  fat  cxcrcted  is  largely  in  the  form  of 

soapt  soaps  which  give  solid  consistency  to  the  stool. 

When  the  normal  amount  of  soap  is  present 
there  is  no  excessive  acidity.  The  action  of 
soaps  to  a  certain  degree  seems  to  be  to  pro- 
tect the  mucous  membrane  of  the  intestine 
from  injury  by  the  products  of  excessive  fer- 
mentation of  the  carbohydrates.  The  acidity 
of  the  stool  is  to  a  great  extent  dependent 
upon  the  relative  proportions  of  fat  and  car- 
bohydrate in  the  diet. 

Aside  from  these  reasons  for  regarding  the 
fat  per  se  as  an  important  constituent  of  the 
diet  of  the  child,  it  must  not  be  forgotten  that 
as  a  source  of  energy  fat  proWdes  more  than 
twice  as  many  calories  per  gram  as  does 
either  protein  or  carbohydrate. 

It  seems,  therefore,  quite  clear  that  a  cer- 
tain amount  of  fat  is  desirable  and  probably 
essential  for  the  best  nutrition  of  the  growing 
child.  The  quantity  needed,  however,  is  diffi- 
cult to  determine.  At  the  present  time  it  can 
only  be  conjectured.  Many  authorities  think 
that  the  diet  naturally  chosen  is  an  indication 
of  a  physiological  need.  That  fat  is  an  impor- 


FAT  REQUIREMENT  115 

tant  component  of  the  diet  of  the  infant  is 
shown  by  the  composition  of  woman's  milk. 
The  normal  amount  of  fat  in  woman's  milk  Amo-mt 
averages  between  3  and  4  per  cent;  and  f^*^^ 
this  furnishes  approximately  half  the  total 
calories  in  the  diet  of  the  nursing  infant. 
This  cannot  be  without  significance.  It  seems 
hardly  conceivable  that  so  much  fat  would 
be  supplied  by  nature  if  the  only  specific  pur- 
pose of  the  fat  were  to  furnish  vitamine  A. 
The  nursing  infant  usually  receives  during 
the  early  weeks  as  much  as  20  grams  of  fat 
daily.  This  total  increases  by  the  seventh 
month  up  to  an  average  of  40  grams  daily. 
This  represents  about  4  grams  per  kilo,  of 
body  weight.  Nothing  is  more  characteris- 
tic in  the  nutrition  of  the  nursing  infant  than 
the  facility  with  which  this  large  amount  of 
fat  is  taken  and  utilised.  Nothing  certainly 
contributes  so  much  to  firm  tissues  and  the 
appearance  of  perfect  health  as  this. 

Fat  is  also  generously  provided  by  nature 
for  the  young  of  all  mammals.  All  the  ani- 
mal milks  contain  a  large  amount  of  fat,  many 
of  them  in  greater  proportion  even  than  is 
found  in  woman 's  milk.  It  is  also  noteworthy 
that  in  nearly  all  milks  the  amounts  of  fat 
and  protein  run  almost  parallel. 

The  infant  fed  on  modifications  of  cow's 


116 


FOOD,    HEALTH  AND   GROWTH 


XnfftQta  Cui 
Take  Less 

r»tin 
Cow's  BCUk 


Amotmt  of 
Fat  Taken 
by  Older 
OUldren 


milk  seldom  receives  as  much  as  does  the 
nursing  infant.  This  is  mainly  because  the  di- 
gestion of  the  fat  of  cow's  milk  is  somewhat 
difficult  for  most  infants  and  it  must  there- 
fore be  given  in  smaller  amounts  and  in- 
creased cautiously.  The  fat  intake  must  be 
varied  with  the  individual  reaction  of  the  in- 
fant to  the  fat  of  cow's  milk.  A  few  infants 
can  take  more  than  this  mth  advantage; 
many  must  be  given  less. 

Although  there  are  in  the  literature  many 
statements  regarding  the  amount  of  fat 
recommended  for  children  after  infancy  there 
are  but  few  records  of  the  amounts  of  fat 
taken  by  individual  children,  and  few  ob- 
servations as  to  the  effects  of  either  a  very 
high  or  a  very  low  fat  intake.  The  amount 
of  fat  taken  by  over  one  hundred  normal 
children  studied  by  us  may  perhaps  be  re- 
garded as  typical  of  that  usually  taken  by 
healthy  children.  Over  throe-fourths  of  these 
children  took  between  2  and  4  grams  per 
kilo,  daily.  The  average  for  both  sexes  dur- 
ing the  early  years  was  a  little  over  3  grams 
per  kilo,  of  body  weight.  As  age  advanced 
there  was  a  gradual  reduction  in  the  grams 
of  fat  per  kilo.  Most  of  the  instances  of  very 
high  fat  intake  were  in  children  of  extreme 
activity  whose  total  food  intake  was  high. 


PAT  REQUIREMENT  117 

Two  boys  in  their  fifteenth  and  sixteenth 
years,  respectively,  took  over  150  grams  of 
fat  daily.  There  is  a  practically  steady  in- 
crease with  age  in  the  average  total  fat  in- 
take, the  maximum  being  reached,  as  would 
be  expected,  during  the  fifteenth  and  six- 
teenth years. 

Miiller  gives  the  average  fat  intake  of 
thirty-two  children  from  two  to  six  years  of 
age  as  3.45  grams  per  kilo.  This  is  in  accord 
with  our  findings  for  corresponding  ages. 

Most  of  the  observations  reported  by  other  low  r»* 
German  authors  show  lower  values.    Those  GeTm»n' 
of  Camerer,  who  has  been  Avidely  accepted 
as  an  authority,  are  especially  low,  most  of 
his  values  being  less  than  1.5  grams  per  kilo. 

Among  the  German  authors  who  have  pro- 
posed a  scheme  of  feeding  in  which  exact 
quantities  of  the  food  constituents  are  given, 
Steffen  is  about  the  only  one  who  recom- 
mends a  generous  fat  intake.  Pirquet  has 
taken  the  position  that  fat  is  not  a  funda- 
mentally essential  article  of  diet  and  that 
it  can  be  replaced  by  carbohydrate  without 
harm  to  the  organism. 

In  Gephart's  report  upon  the  diet  of  the 
boys  of  St.  Paul 's  School  he  states  that  they 
took  about  200  grams  of  fat  daily. 

The   younger   group,   averaging   thirteen 


118 


FOOD,   HEALTH  AND  GROWTH 


Amotint 
Tak«a  by 
▲dolMccnt 
B07i 


Syaptoma 
from  Too 
Much  r»t 


and  one-half  years  of  age,  took  an  average  of 
4.5  grams  of  fat  per  kilo.,  and  the  older  group, 
averaging  sixteen  and  one-half  years,  took 
3.4  grams  of  fat  per  kilo.  All  these  values 
are  much  higher  than  has  been  thought  normal. 

The  average  adult  diet  based  on  many  ob- 
servations contains  only  about  half  the 
amount  of  fat  taken  by  these  boys.  The  fact 
that  the  fat  intake  of  healthy  boys  was 
so  high  is  undoubtedly  significant.  This 
large  amount  of  fat  apparently  had  no  dele- 
terious effect.  On  the  contrary  the  boys 
thrived  upon  it  and  it  seemed  to  represent  a 
physiological  need.  It  confirms  our  belief 
that  the  fat  requirements  are  especially  large 
during  the  periods  of  most  active  growth  (in- 
fancy and  adolescence)  and  that  at  the  latter 
period  they  exceed  adult  requirements. 

There  is  a  disposition  among  certain  chni- 
cians  to  ascribe  most  of  the  digestive  disturb- 
ances in  children  taking  a  mixed  diet  to  the 
fat  in  the  food,  particularly  the  fat  of  cow's 
milk.  It  is  undoubtedly  true  that  under  cer- 
tain conditions  a  very  high  intake  of  fat,  par- 
ticularly if  accompanied  by  a  reduction  in 
the  carbohydrate  intake,  may  bring  about 
quite  serious  disturbances  of  digestion.  Ger- 
man writers  describe  it  under  the  name  Milch- 
ndhrschadcn.     The  characteristic  symptoms 


PAT  REQUIREMENT  119 

in  such  cases  are  familiar :  the  coated  tongue, 
bad  breath,  general  malaise,  constipation, 
with  large  gray  stools  containing  a  high  pro- 
portion of  fat,  and  occasionally  severe  and 
prolonged  attacks  of  vomiting. 

These  symptoms  are  regularly  relieved  by 
greatly  reducing  fats  and  increasing  carbo- 
hydrates in  the  diet. 

There  are  many  other  cases,  however, 
when  fat  is  blamed,  when  the  real  cause  is 
simply  too  much  food;  as  when  children  of 
limited  activity  are  given  a  quart  or  more  of 
milk,  often  rich  milk  too,  daily,  in  addition  Anun- 
to  a  liberal  diet  of  solid  food.  It  is  important  duS^'^ 
before  attributing  the  trouble  to  the  fat  to 
consider  the  diet  as  a  whole,  both  as  to  the 
total  amount  of  food  taken  and  the  relative 
amounts  of  fat  and  carbohydrate  which  the 
diet  contains.  There  is  evidence  that  when 
the  diet  is  properly  balanced,  that  is,  con- 
tains the  fat,  protein  and  carbohydrate  in 
the  right  relation  to  each  other,  a  child  can  di- 
gest very  much  larger  amounts  of  fat  than 
when  the  diet  is  unbalanced. 

While  it  may  not  yet  be  proven  that  a  large 
amount  of  fat  is  essential  in  the  diet  during 
growth,  there  are  so  many  reasons  for  a  lib- 
eral allowance  of  fat,  and  so  little  evidence  ff*J»S^° 
that  this  is  harmful,  that  it  does  not  seem  SSiSiiTbi* 


120 


FOOD,   HEALTH  AND   GROWTH 


Amount 
B*com- 
m«ad*d 


wise,  with  our  present  knowledge,  to  en- 
deavour to  reduce  the  fat  in  the  diet  to  a  mini- 
mum, or  even  to  give  much  less  than  the 
amount  which  healthy  children  usually  take 
at  the  present  time;  while  to  exclude  it  en- 
tirely from  the  diet  seems  quite  unjustifiable. 
From  the  foregoing  considerations  it  seems 
reasonable  to  allow  growing  children  in  the 
diet  at  least  as  much  fat  as  protein.  On  this 
basis,  the  proper  amount  seems  to  be  nearly 
4.0  grams  per  kilo,  daily  at  one  year,  dimin- 
ishing to  about  3.0  grams  or  0.3  per  cent  of 
the  body  weight  at  six  years  and  thereafter. 
It  seems  probable  that  the  child's  nutrition  is 
best  assured  by  not  permitting  the  fat  allow- 
ance to  fall  much  below  this  value  during 
the  remainder  of  the  growth  period. 


Functions 
of  Carboby- 
drate  In 
Diet 


in.    Carbohydrate  Requirement 

The  carbohydrates  probably  have  no  spe- 
cific function  to  perform  in  the  diet  of  the 
growing  child  but  are  nevertheless  very  es- 
sential components.  They  serve  mainly  as  a 
source  of  energy,  supplying  the  necessary 
calories  not  furnished  by  fat  and  protein.  In 
many  respects  fats  and  carbohydrates  in  the 
diet  are  interchangeable,  so  that  in  conditions 
of  marked  fat  intolerance  carbohydrates  may 
entirely    replace    fats    for    a    considerable 


CARBOHYDRATE  REQUIREMENT  121 

period.  However,  carbohydrates  accomplish 
other  purposes.  They  undoubtedly  play  an 
important  part  in  the  metabolism  of  fat; 
mthout  the  addition  of  carbohydrate  to  the 
diet  it  is  generally  believed  that  complete  me- 
tabolism of  fat  is  impossible.  In  its  capacity 
to  spare  protein  carbohydrate  is  even  su- 
perior to  fat.  These  functions  of  carbohy- 
drate are  well  kno^vll  and  need  not  be  dis- 
cussed. 

"When  digestion  is  normal,  carbohydrate  is 
almost  if  not  quite  completely  utilised  in  the 
body.  What  is  not  immediately  used  for  en- 
ergy is  stored  as  glycogen  to  be  later  used 
for  energy,  or  it  is  converted  into  fat  and 
added  as  fat  to  the  tissues  of  the  body.  The 
excess  is  usually  broken  do^\^l  by  fermenta- 
tion in  fhe  intestines.  While  of  all  the  food 
constituents  it  is  most  easily  and  most  com- 
pletely digested  under  normal  conditions, 
when  digestion  is  disturbed  it  is  the  one 
which  breaks  dovm.  readily  to  form  irritating 
products  in  the  intestine. 

The  carbohydrates  are  altogether  the  most 
economical  food  we  possess  from  both  a  com-  our  Most 

•     1  ^  1-1-1  ■     ,.        D        •  Economical 

mercial  and  a   physiological  point   or   view,  rood 
They  can  be  produced  more  cheaply;  because 
not  perishable  they  can  be  transported  and 
stored  with  less  expense  and  less  hkelihood 


122 


FOOD,   HEALTH  AND   GROWTH 


of  deterioration.  They  are  consequently 
much  less  expensive  than  fat  and  protein 
foods.*  They  are  economical  physiologically 
because  of  their  almost  complete  utilisation 
tmder  normal  conditions.  It  is  not  surpris- 
ing therefore  that  carbohydrate  has  come  to 
form  the  greatest  part  of  the  diet  at  all  peri- 
ods of  life  except  early  infancy. 


*Caloeies  Pubchasable  roR  Ten  Cents  at  a  Small  New 
York  Retail  Store  on  a  Given  Date 


Articles 

Retail  Price 

Number  of 
Calories 

Carbohydrate  foods 

Sugar,  granulated 

6  cents  per  pound 

3100 

Karo  Corn  Syrup 

20  cents  per  2.5  lb.  can 

1970 

Oatmeal 

12  cents  per  20  oz.  pkg. 

1930 

Rice 

12  cents  per  pound 

1360 

Bread 

9  cents  per  15  oz.  loaf 

1270 

Cream  of  Wheat 

30  cents  per  28  oz.  pkg. 

980 

Potato 

5  cents  per  pound 

770 

Jam 

20  cents  per  lb.  jar 

530 

Fat  foods 

Butter 

49  cents  per  pound 

740 

Olive  oil 

65  cents  per  pint 

600 

Cream— Sheffield  X 

(includes  some  pro- 

tein and  sugar) 

?>2  cents  per  half  pint 

240 

Protein  foods   (include 

some  fat) 

Cheese,   American 

35  cents  per  pound 

590 

Lean  beef,  round 

44  cents  per  pound 

200 

Eggs,  fresh  brown 

60  cents  per  dozen 

180 

Mixed  food 

Milk— Sheffield, 

Grade  A 

18  cents  per  quart 

355 

CARBOHYDRATE  REQUIREMENT  123 

But  even  at  this  time  the  lactose  of  J^S^* 
woman's  milk  supplies  nearly  one-half  of  its  S£S«*' 
caloric  value.  The  nursing  infant  takes  daily 
about  30  grams  of  lactose  during  the  early 
weeks  and  usually  as  much  as  80  grams  dur- 
ing the  latter  part  of  the  nursing  period. 
Young  infants  taking  modifications  of  cow's 
milk  often  receive  considerably  more  carbo- 
hydrate than  do  nursing  infants.  This  is 
chiefly  because  it  is  impossible  to  give  them 
the  amount  of  fat  which  the  nursing  infant 
usually  receives. 

The  nursing  infant  receives  carbohydrate 
entirely  in  one  form — lactose.  The  infant 
fed  on  cow's  milk  may  take  entirely  lactose  or 
partly  lactose  and  partly  saccharose,  mal- 
tose, dextrin  or  starch  or  various  combina- 
tions of  these.  It  is  not  usual  for  any  large 
proportion  of  the  carbohydrate  to  be  given 
as  starch  until  after  infancy,  when  the  child 
takes  a  mixed  diet.  In  a  mixed  diet  after 
one  year  at  least  one-half  of  the  carbohy- 
drate is  usually  in  the  form  of  starch,  the 
rest  being  various  sugars — milk  sugar,  cane 
sugar  and  fruit  sugar  and  occasionally  some 
dextrin  or  maltose. 

The  amount  of  carbohydrate  taken  by  chil- 
dren over  one  year  of  age  varies  consider- 
ably according  to  the  theories  of  the  parent 


124 


FOOD,   HEALTH  AND   GROWTH 


IMtpositlon 
to  FMd 
Too  Much 
Carboby- 
<lr»t« 


Amount 
T&ken  by 
Healthy 
Cbildren  In 
XTsaal  Diet 


or  physician  and  even  more  to  the  habit  or 
taste  of  the  child. 

On  account  of  the  conditions  mentioned 
there  is  at  present  a  growing  tendency  to  al- 
low carbohydrate  foods  to  form  a  larger  and 
larger  proportion  of  the  diet.  There  are  some 
children  the  largest  item  of  whose  diet  is 
bread;  with  others  it  is  potato  or  cereal. 
There  is  also  a  steady  increase  in  the  con- 
sumption of  sugar  and  sweets  by  all  classes. 
One  hundred  3'ears  ago  the  per  capita  con- 
sumption of  sugar  in  the  United  States  was 
eight  pounds;  last  year  it  was  84  pounds. 
This  is  either  taken  as  sugar  in  or  upon  food 
or  in  the  form  of  syrup,  jelly,  jam,  candy,  etc. 
An  ofiBcial  of  one  of  the  large  five  and  ten 
cent  store  corporations  has  made  the  state- 
ment that  their  annual  sales  of  candy  ex- 
ceeded 60,000  tons ! 

The  carbohydrate  intake  which  was  calcu- 
lated of  over  one  hundred  healthy  children 
studied  by  us  ^  illustrates  the  wide  variation 
in  the  usual  diet  of  normal  healthy  children. 
Since  the  ages  of  the  children  varied  from 
one  to  eighteen  years  the  variation  in  intake 
is  best  shown  per  kilo,  of  body  weight.    The 

*  The  details  of  these  observations  showing  intake  of  the 
individual  cases  have  been  publisiied  elsewhere — see  Am^ri- 
ccn  Journal  Diseases  of  Onldrcn,  Julv,  1922. 


CARBOHYDRATE  REQUIREMENT  125 

usual  range  was  from  8  to  12  grams  per  kilo. ; 
the  average  of  all  the  eases  being  about  10 
grams.  There  were  more  instances  of  very 
high  than  of  very  low  intake.  In  a  number 
of  cases  the  children  took  over  15  grams  per 
kilo. 

The  actual  amounts  of  carbohydrate  taken 
by  the  different  children  were  also  interest- 
ing. There  were  few  instances  of  very  low 
intake;  there  were,  however,  several  exceed- 
ingly high  ones.  One  girl,  between  eight  and 
nine  years  of  age,  took  464  grams  of  carbo- 
hydrate daily.  One  boy  of  nine  took  560 
grams;  one  of  ten  took  488  grams;  and  one 
of  fourteen  took  683  grams  daily.  The  total 
daily  intake  increased  with  fair  regularity 
with  the  years.  The  boys  averaged  more 
than  the  girls  except  during  the  earliest 
years. 

The  observations  reported  in  the  literature, 
in  which  the  carbohydrate  intake  of  children 
after  infancy  was  ascertained,  showed  varia- 
tions quite  as  wide  as  those  in  our  own  cases. 
In  general,  the  amount  of  carbohydrate  per 
kilo,  of  body  weight  reported  taken  by  young 
children  is  higher  than  that  taken  by  older 
children. 

Gephart  found  that  the  anionnt  of  carbo- 
hydrate  taken   by    the   boys    at    St.    Paul's 


126  FOOD,   HEALTH  AND  GROWTH 

School  was  much  in  excess  of  the  average 
adult  consumption  and  averaged  over  600 
grams  daily.  Part  of  the  large  intake  of  these 
boys  is  to  be  explained  by  sweets  they  con- 
sumed. The  carbohydrate  intake  repre- 
sented an  average  of  13.7  grams  per  kilo,  for 
the  youngest  group  about  thirteen  years  old, 
and  10  grams  for  the  older  group  averaging 
sixteen  years. 
What  Older  How  much  this  Tcpresents  can  best  be 
Ad^ts"Take  judgcd  by  comparisou  with  the  usual  adult 
dietary  which  allows  400  to  550  grams  daily 
and  which  is  from  5  to  8  grams  per  kilo,  of 
body  weight.  Murlin  found  that  the  men 
in  the  U.  S.  Army  training  camps  took  an 
average  of  545  grams  of  carbohydrate  daily, 
or  about  8  grams  per  kilo,  of  body  weight. 

From  the  data  obtained  concerning  the  diet 
taken  by  the  group  of  normal  children  studied 
it  was  possible  to  calculate  very  approxi- 
mately the  amounts  of  sugar  and  starch 
which  made  up  the  total  carbohydrate. 

The  values  obtained  are  only  approximate, 
since  the  relative  amounts  of  sugar  and 
starch  used  in  cooking  various  articles  of 
food  such  as  cake,  puddings,  etc.,  could  in 
most  cases  be  only  estimated  from  a  knowl- 
edge of  common  recipes.  It  is  believed  how- 
ever that  these  estimates  are  fairly  accurate. 


128 


FOOD,  HEALTH  AND  GROWTH 


About  Half 
tlie  Carbo- 
hydrate 
Taken  Is 
Sugar 


It  was  quite  surprising  to  find  that  the  av- 
erage of  all  the  cases,  regardless  of  age, 
showed  that  51  per  cent  of  the  carbohydrate 
taken  was  sugar  of  some  form.  The  range 
of  sugar  taken  was  naturally  wide,  but  in 
over  two-thirds  of  the  cases  it  was  between 
40  and  60  per  cent  of  the  total  carbohydrate. 

In  the  accompanj-ing  chart  (Fig.  13)  the 
proportions  of  starch  and  sugar  are  given, 
arranged  according  to  age,  the  heavy  verti- 
cal lines  dividing  the  years.  This  shows  com- 
paratively httle  variation  with  the  ditferent 
children  in  the  proportion  of  the  carbohy- 
drate which  was  taken  as  starch  and  sugar. 

It  is  apparently  usual  in  a  mixed  diet  of 
healthy  American  children  to  give  uncon- 
sciously practicall}"  equal  amounts  of  starch 
and  sugar.  It  should  be  noted  that  sugar 
here  includes  not  only  the  saccharose  used 
in  cooking  or  on  cereal,  candy,  etc.,  but  also 
the  fruit  sugars  and  the  lactose  of  the  milk 
which  was  taken  separately  or  which  was 
used  in  cooking. 

It  was  also  possible  to  estimate  the  pro- 
portions of  different  sugars  constituting  the 
sugar  intake  of  the  different  children.  There 
was  little  regularity  seen  in  the  proportions 
of  different  sugars  taken ;  in  the  early  years 
lactose   supplied   the   largest   proportion   of 


CARBOHYDRATE  REQUIREMENT  129 

the  sugar.  The  proportion  of  saccharose 
increased  with  advancing  years.  There  was 
a  steady  increase  with  the  years  up  to  the 
eleventh  year;  during  adolescence  it  was 
about  ten  times  as  much  as  the  average  taken 
by  children  under  five  years  of  age. 

It  is  surprising  to  note  how  much  of  the 
sugar  intake  was  supplied  by  fruits.  This 
was  largely  fructose,  but  some  of  it  was  sac- 
charose and  it  included  also  in  some  instances, 
as  in  the  banana,  a  small  amount  of  starch. 
Other  sugars  played  a  very  insignificant  part 
in  the  sugar  intake. 

Because  of  the  ease  with  which  carbohy- 
drate is  utilised  in  the  body  and  because  of  obj«ction« 

•'  to  Too 

its  lower  cost,  there  is  a  constant  tendency  ^^^y^^f/,^" 
to  allow  carbohydrate  food  to  form  an  exces-  ^  °^®* 
sive  proportion  of  the  diet.  There  are  sev- 
eral disadvantages  in  this  procedure.  If  the 
proper  number  of  calories  is  taken,  a  very 
high  proportion  of  carbohydrate  means  a  low 
proportion  of  either  fat  or  protein  or  both. 
Hence  there  always  exists  the  danger  of  low- 
ering the  amount  of  fat  or  protein  below  that 
which  is  necessary  for  normal  nutrition.  In 
such  instances  there  may  result  an  excessive 
retention  of  water  in  the  tissues  of  the  body. 
A  diet  excessive  in  carbohydrate  often 
leads  also  to  an  abnonnal  deposition  of  fat  in 


130 


FOOD,   HEALTH  AND  GROWTH 


Pigs  r*d  on 
Condensed 


the  body.  Such  a  condition  is  more  frequently 
seen  in  infancy  where  the  food  is  condensed 
milk  or  some  one  of  the  proprietary  infant 
foods  which  are  largely  composed  of  carbo- 
hydrates. The  tissues  of  such  infants  are 
high  in  fat  and  water  but  low  in  muscle  de- 
velopment. If  acute  disturbance  of  diges- 
tion or  infection  takes  place  this  unnatural 
weight  is  rapidly  lost.  The  children  have  but 
feeble  resistance  and  they  often  succumb 
quickly. 

A  similar  condition  was  produced  experi- 
mentally in  pigs  by  Washburn  and  Jones. 
They  found  that  young  pigs  fed  upon  sweet- 
ened condensed  milk  put  on  an  excessive 

COMPABISON    OF   GeOWTH   IN   SEVEN   WEEKS   OT  SiX   PlOS   ON 
CJONDENSED   MiLK   WITH  SiX   PiGS  ON   WHOLE  MiLK 


Feeding 

So 

'c 

g 

0.  o  a 

4 

in 

aM£. 

Whole  milk 

1370 
1270 

11.35 
8.10 

9.2 
23.65 

15.61 
10.92 

362 

Sweetened  condensed  milk 

243 

Whole  milk  contained  fat  3.3 ;  sugar  5.2 ;  protein  3.6  per 
cent. 

Sweetened  condensed  milk  contained  fat  1.6;  sugar  9.8; 
protein  1.6  per  cent. 


amount  of  fat.    The  protein  increase  in  their 
bodies  was,  however,  much  below  normal  and 


CARBOHYDRATE  REQUmEMENT  131 

the  bone  development  was  defective,  the 
bones  being  only  two-thirds  as  strong  as  when 
whole  milk  was  fed.  The  table  gives  a  smn- 
mary  of  some  of  their  findings. 

There  is  a  growing  belief  that  the  large  and 
constantly  increasing  proportion   of  carbo- 
hydrate in  the  diet  of  civilised  races  has  a 
very  important  relation  to   the  prevalence 
of  dental  caries.    The  observation  has  been 
made  by   several  investigators   that  Arctic  g^^Jf*'* 
peoples  whose  diet  is  almost  entirely  fat  and  Sd^ui 
protein   with  but  very  little   carbohydrate,  °"^*" 
rarely  suffer  from  dental  caries.     "Whether 
this  tendency  is  due  to  the  excess  of  carbohy- 
drate or  to  the  consequent  reduction  of  other 
constituents  of  the  diet — fat,  protein,  mineral 
salts  or  vitamines — has  not  yet  been  estab- 
lished. 

Of  more  importance  probably  is  the  effect 
on  digestion  of  a  diet  in  which  the  proportion 
of  carbohydrate  is  excessive.  If  a  large 
amount  of  carbohydrate,  especially  if  in  the 
form  of  sugar,  is  taken  into  the  digestive  ^n'^^'^''/ 
tract  at  one  time,  it  is  often  impossible  for  i>i«««woa 
absorption  to  proceed  at  a  rate  rapid  enough 
to  take  care  of  this  amount,  and  the  conse- 
quence is  excessive  fermentation  due  to  bac- 
terial action;  this  leads  to  the  formation  of 
gases  and  irritating  organic  acids.    The  re- 


132  FOOD,   HEALTH   AND   GROWTH 

suit  may  be  loose,  irritating,  acid  stools. 
Sometimes  there  may  be  serious  diarrhoea. 
If  the  excess  iu  carbohydrate  is  in  the  form 
of  starchy  food  there  may  be  constipation 
with  abdominal  distention,  flatulence  and 
colic.  Usually  these  disorders  of  digestion 
are  acute  and  not  very  severe,  yielding 
quickly  to  proper  dietetic  treatment.  When, 
however,  they  are  frequently  repeated  or 
are  prolonged  because  the  dietetic  error  is 
not  corrected,  they  may  lead  to  serious 
chronic  disturbances  with  marked  loss  in 
weight. 

It  has  been  shown  that  a  fairly  definite 
amount  of  protein  must  be  included  in  the 
diet  of  a  growing  child;  it  seems  altogether 
probable  that  it  is  best  to  include  at  least  an 
equal  amount  of  fat.  When  these  have  been 
provided,  the  remainder  of  the  total  calories 
needed  at  any  age  will  determine  the  amount 
Auowance      of  carbohvdrate.     On  this  basis  it  appears 

for  Aver-  •'  ti 

age  chud  reasonable  to  allow  as  an  average  diet  about 
12  grams  of  carbohydrate  per  kilo,  at  one 
year  decreasing  to  between  9  and  10  grams 
per  kilo,  at  six  years  and  maintaining  about 
this  value  throughout  the  remainder  of  the 
growth  period. 

If  the  total  caloric  need  is  increased  much 


CARBOHYDRATE  REQUIREMENT  133 

above  the  average  because  of  unusual  muscu- 
lar activity,  carbohydrate  may  supply  the 
entire  amount  of  extra  energy,  since  an  in- 
crease in  muscular  activity  does  not  increase 
the  protein  need  above  the  normal. 

Carbohydrate  is  a  desirable  and  probably  summary 
an  essential  component  of  the  diet,  although 
it  does  not  have  any  specific  function  in 
nutrition.  It  forms  the  largest  part  of  the 
diet  at  all  periods  of  life  and  furnishes  the 
calories  needed  in  the  diet  which  are  not 
supplied  by  the  requisite  amounts  of  fat  and 
protein. 

The  carbohydrate  intake  of  over  one  hun- 
dred healthy  children  from  one  to  eighteen 
years  of  age,  studied  by  us,  averaged  10 
grams  per  kilo.  Of  this  51  per  cent  were 
sugars,  including  lactose,  saccharose,  and 
fructose,  and  49  per  cent  was  starch. 

Carbohydrate  is  more  economical  than  fat 
or  protein,  both  physiologically  and  com- 
mercially. Because  of  this  latter  advantage 
there  is  a  g^o^vdng  tendency  to  increase  the 
proportion  of  carbohydrate  in  the  diet  beyond 
the  amount  which  is  desirable. 

When  a  verj'  large  proportion  of  the  food 
is  in  the  form  of  carbohydrate  the  intake  of 
fat  or  of  protein  or  of  both  is  likely  to  be  less 


134  FOOD,    HEALTH   AND   GROWTH 

than  the  normal  nutritive  need  of  the 
body. 

A  diet  excessive  in  carbohydrate  leads  to 
an  abnormal  deposition  of  fat  without  a  cor- 
responding increase  in  muscle  development. 
Children  taking  such  a  diet  have  feeble  resist- 
ance to  infection. 

There  is  much  evidence  that  a  relation 
exists  between  the  high  proportion  of  carbo- 
hydrate in  the  modern  diet  and  the  preva- 
lence of  dental  caries. 

Digestive  disturbances,  chiefly  intestinal, 
may  be  produced  when  the  carbohydrate  in 
the  diet  is  excessive.  There  may  result  in- 
creased fermentation  w^th  loose  acid  stools 
or  constipation  with  flatulence  and  abdominal 
distention.  When  long  continued,  these  dis- 
turbances are  ver^^  difficult  to  control. 

It  seems  rational  to  allow  in  the  diet  of  the 
child  of  average  activity  about  12  grams  of 
carbohydrate  per  kilo,  of  body  weight  at  one 
year,  decreasing  the  amount  to  about  10 
grams  per  kilo.,  or  1  per  cent  of  the  body 
weight,  at  six  years  and  maintaining  it  at  this 
value  through  the  remainder  of  the  growth 
period. 

If  because  of  unusual  activity  the  total 
caloric  requirement  is  increased  this  increase 
can  be  supplied  by  carbohydrates  alone. 


MINERAL  SALTS  135 


IV.    Mineral  Salts 


Specially 


A  discussion  of  the  mineral  salts  need  not 
be  entered  into  at  length;  yet  a  few  words 
seem  necessary.  While  not  sources  of  energy 
they  are  just  as  necessary  constituents  of  the 
diet  as  are  fat,  protein  and  carbohydrate. 
^They  are  in  fact  indispensable  to  growth  and 
normal  nutrition. 

None  of  the  formal  physiological  functions 
of  the  body,  such  as  secretion,  excretion 
or  osmosis, vxjan  go  on  without  them.  These 
facts  have  all  been  well  known  for  many 
years. 

Their  special  importance  in  childliood  re- 
lates to  the  fact  that  at  this  period  they  have  i,u?tag'^* 
an  added  function  in  promoting^  growth.  °" 
This  relates  obviously  to  the  gro^'th  of  the 
skeleton.  But  there  is  evidence  that  they 
have  other  functions  in  growth  not  so  well 
understood.  The  effect  upon  the  develop- 
ment of  bones  of  a  diet  deficient  in  mineral 
salts  is  well  known.  It  is  very  marked  but 
occurs  slowly.  However,  the  degree  to  which 
growth  and  gain  in  weight  are  influenced  by 
the  mineral  salts  in  the  diet  is  not  so  gener- 
ally appreciated.  How  great  this  is  and  how 
quickly  the  effects  are  manifested  are  indi- 
cated by  the  growth  curves  of  rats  in  the  ex- 


136  POOD,    HEALTH  AND   GROWTH 

periments  of  Osborne  and  Mendel  (Fig.  14). 
The  first  curve  shows  slow  growth  •with  a  diet 
low  in  calcium,  a  sharp  rise  when  calcium  in 
adequate  amount  is  supplied,  a  cessation  of 


GROWTH  WITHflinS  OmCIENT  III  MINERAL  SALTS 


•mmMIKT  low  ■  CiLCIBH 
■■IBilET  IMhS  m  CALCWM 


iBiET  LOW  ra  pMosraom 
■oin  *Mru  10  nosraoHS 


Fig.  14. 


growi:h  when  this  is  reduced,  and  a  sharp  rise 
when  it  is  again  added.  The  second  curve 
shows  the  same  thing  with  reference  to  phos- 
phorus. The  diet  was  essentially  the  same 
throughout  except  in  its  salt  content. 


MINERAL   SALTS  137 

PhosphorgLS  and  in  fact  most  of  the  inor- 
ganic salts  are  so  abundantly  supplied  in  all 
our  foods  that  there  is  little  likelihood  of  a 
deficiency  in  any  of  them  when  the  usual  diet 
is  taken.  There  are,  however,  two  which  may 
be  deficient  and  whose  importance  is  so  great 
that  the  lack  is  evident  in  the  nutrition,  viz., 
iron  and  calcium. 

The  very  lowiron  content  of  cow 's_,  milk 
constitutes  one  of  its  important  deficiencies 
as  a  food  for  infants  and  very  young  children. 
If  the  diet  consists  largely  or  almost  ex- 
clusively of  mi]k  for  a  prolonged  period  there 
is  frequently  seen  a  degree  of  anaemia  which 
may  be  very  disturbing.  This  most  often  oc-  Sw'i^^Sa 
curs  when  a  child  because  of  the  indulgence 
of  parents  or  nurses  has  not  been  weaned 
from  a  bottle  at  two  or  sometimes  at  three 
years,  and  in  consequence  persistently  re- 
fuses all  other  food  than  milk  from  the  bottle. 
This  is  perhaps  the  most  important  reason 
for  beginning  the  use  of  other  foods  than 
milk  at  an  earlier  period  than  was  formerly 
the  practice.  >^  a  child  at  eleven  or  twelve 
months  is  taking  fruit  juice,  beef  juice,  ogg 
and  some  pureed  vegetable,  the  supply  of 
iron  needed  is  provided. 

Our  chief  sources  of  calcium  are  milk,  eggs 
and  vegetables,   especially  the  gjreen  vege- 


138  FOOD,    HEALTH   AND   GROWTH 

tables.  The  quantity  of  green  vegetable 
which  can  be  given  to  a  young  child  is 
small  and  the  number  of  eggs  which  can 
be  allowed  in  the  diet  is  limited.  Besides, 
the  amount  of  calcium  in  vegetables  is  not 
large.  A  good  helping  of  spinach,  which 
is  the  richest  of  our  vegetables  in  this  min- 
eral, contains  only  as  much  calcium  as  does 
one  ounce  of  milk,  and  one  egg  has  but  a 
httle  more  than  this  amount. 

The  importance  of  milk  as  a  source  of  cal- 
cium becomes  at  once  apparent  and  it  matters 
little  whether  it  is  milk  w^hich  is  drunk  or 
milk  used  in  the  preparation  of  other  food; 
or  whether  milk  is  raw,  pasteurised,  skimmed, 
dried  or  condensed,  its  value  from  this  point 
of  view  is  not  essentially  altered  by  these  pro- 
cedures. If  a  pint  of  milk  daily  is  included  in 
the  diet,  an  adequate  supply  of  calcium  is 
probably  assured. 

It  has  not  been  established  that  any 
amount  of  calcium  or  any  other  mineral  salt 
that  is  likely  to  be  taken  in  the  diet  produces 
in  health  any  ill  effects  whatever.  ^The  soluble 
ones  are  ehminated  chiefly  by  the  kidneys, 
the  insoluble  ones  by  the  intestines.  Jt  is 
well  know^i  that  verj'  large  amounts  of 
sodium  chlorid  may  in  infants  produce  seri- 
ous disturbances  of  nutrition. 


DISTRIBUTION  OF  CALORIES  139 

It  is  of  course  in  relation  to  the  production  ?Sf.p°o?5^* 
of  rickets  that  the  particular  interest  in  the  ytSd^*^ 
mineral  salts  of  the  diet  just  now  centers.  "'^**"^'' 
That  an  adequate  intake  of  calcium  and  phos- 
phorus is  essential  to  normal  bone  develop- 
ment is   obvious.     But   rickets  occurs  con- 
stantly in  spite  of  this.    Besides  an  adequate 
supply  in  the  food  there  are  other  conditions 
necessary  to  a  proper  utilisation  of  these  sub- 
stances.   What  these  all  are  we  do  not  as  yet 
fully  understand.    That  there  is  more  than 
one  dietary  factor  seems  established. 

While  therefore  mineral  salts  are  so  es- 
sential in  the  diet,  we  need  not  fear  that  the 
requirements  of  the  body  in  this  respect  dur- 
ing growth  will  not  be  met,  unless  for  long 
periods  the  diet  is  a  very  restricted  one,  and 
especially  if  it  contains  no  milk,  eggs  or  green 
vegetables. 

V.    Percentage  Distribution  of  Calories. 

Thus  far  there  have  been  discussed  the 
total  caloric  need  and  the  amounts  of  the 
different  food  constituents — protein,  fat  and 
carbohydrate — which  make  up  the  diet  of  the 
average  healthy  child,  ijhe  next  point  to  be 
considered  is  the  relation  of  these  food  con- 
stituents to  eacli_  other,  and  the  relation  of 


140 


DISTRIBUTION   OF   CALORIES  141 

of 


each  one  to  the  diet  as  a  whole ;  (hi  other  5Sr"od 
words,  what  percentage  of  the  total  calories  S""* "" 
shaU  be  given  as  fat,  as  protein  and  as  car-  ^*<^o*^" 
bohydrate. 

In  order  to  determine  the  usual  relation  of 
these  constituents  in  the  diet  of  the  child  we 
have  calculated  the  percentage  distribution 
of  the  calories  in  the  diets  taken  by  the  one 
hundred  and  six  healthy  children  from  one 
to  eighteen  years  of  age  studied  by  us.  The 
result  in  the  individual  observations  is  shoAvn 
in  Figure  15.  The  proportion  of  the  total 
calories  taken  as  protein  is  shown  at  the  bot- 
tom, that  as  fat  in  the  middle  and  that  as 
carbohydrate  at  the  top. 

The  proportion  of  the  total  intake  which 
was  protein  showed  the  least  variation.  The 
average  of  all  the  cases,  regardless  of  age, 
was  15  per  cent;  the  range  was  from  11  to 
23  per  cent,  but  over  one-half  the  values  were 
between  14  and  16  per  cent. 

The  Der  cent  of  the  total  calories  taken  as  Narrow 

Variations 

fat  varied  much  more  widely.    The  range  was  ^j^^f^^ 
from  21  to  51  per  cent,  but  three-fourths  of  ^**bo-* 
the  values  were  between  30  and  40  per  cent ;  ^y<^»t« 
the  average  of  all  the  values  was  34  per  cent. 
The  proportion  of  the  total  calories  taken 
as  carbohydrate  also  showed  wide  variation, 
with  a  range  of  from  38  to  65  per  cent;  but 


142 


FOOD,   HEALTH  AND  GROWTH 


three-quarters  of  the  values  were  between  44 
and  55  per  cent ;  the  average  was  51  per  cent. 

There  was  no  regular  variation  with  age, 
although  the  per  cent  of  the  total  calories 
taken  as  protein  was  slightly  higher  in  the 
early  years. 

Although  there  are  fairly  wide  individual 
variations,  it  is  evident  that  in  the  mixed  diet 
commonly  taken  by  healthy  children  the 
calories  are  distributed  with  surprising  regu- 
larity. The  average  of  the  values  obtained 
in  these  cases  may  be  assumed  to  represent 
the  usual  distribution.  This  seems  a  fair  as- 
sumption, when  the  large  number  of  cases  is 
considered,  and  when  it  is  recalled  that  those 
observed  were  not  a  single  group  under  any 
one  supervision,  but  were  children  in  private 
families  in  rather  scattered  localities.  Not 
all  of  the  children  lived  in  New  York  City, 
Several  lived  in  Boston,  two  in  Pittsburg,  one 
in  the  South  and  many  in  New  Jersey  and 
Long  Island. 

Regardless  of  age,  the  average  distribution 
of  the  calories  taken  was  as  follows:  fat  34 
per  cent,  carbohydrate  51  per  cent  and  pro- 
tein 15  per  cent;  conveniently  expressed  in 
round  numbers  as  35-50-15.  Therefore,  a 
healthy  child  takes  on  the  average  practically 
one-half  his  calories  as  carbohydrate,  a  little 


DISTRIBUTION   OF   CALORIES 


143 


more  than  one-third  as  fat  and  only  about 
one-sixth  as  protein.  Since  a  gram  of  fat 
has  two  and  one-fourth  times  the  caloric  value 


w 

Mf 

TMMmC*l. 

mtx 

MILT 

CALttlll 

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vutm 

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—^ 

d 

r^ 

i:^ 

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rH 

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Tig.  17. 

of  a  gram  of  protein,  it  is  evident  that  in  these 
proportions  the  amounts  of  fat  and  protein 
are  practically  equal,  while  the  amount  of 
carbohydrate  is  a  little  more  than  three  times 
as  great  as  either  the  fat  or  protein. 


144 


FOOD,    HEALTH   AND   GROWTH 


Using  the  average  distribution  of  calories 
just  given  the  exact  requirements  in  fat,  car- 
bohydrate and  protein  have  been  calculated 
for  the  entire  period  of  growth,  according  to 
the  estimated  total  caloric  requirements  given 


vUfoa 

raCMCTICU       milt       CALOtllt 

pf 

■lit 

- 

••n 

CMMK9 

M 

"k 

JB 

^53 

ijci  '^^  i*.^ 

1 

Ei^mB 

s^ 

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s!i^^ 

B^raMiH 

k 

.. 

m^mnA 

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T\-\    1        "T^ 

to 

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Fig.  18. 

TMtOltTICiL      atlLT      CtLOtlU       n»     RIU       -   tlM.* 


^w- 


1W«      BDNBNna     T',  MM 


Fig.  19. 

in  the  preceding  lecture.  Those  for  boys  and 
girls  are  given  in  Figures  16  and  17.  The 
per  kilo,  requirements  of  both  sexes  are 
shown  in  Figures  18  and  19. 

As  the  variation  from  the  average  in  the 
total  calories  which  are  needed  by  individual 


DISTRIBUTION    OF    CALORIES  145 

children  is  considerable  there  will  undoubt- 
edly be  variation  in  the  distribution  of  the 
calories.  If  the  total  caloric  requirement  is 
increased  because  of  more  than  average  ac- 
tivity, this  increase  may  be  met,  as  has  been 
previously  stated,  by  raising  the  carbohy- 
drate intake  alone. 

This  would  increase  the  proportion  of  car- 
bohydrate although  the  amounts  of  fat  and  variau^s 
protein  remain  unchanged.  When  the  total 
caloric  need  is  lessened  because  a  child  is 
over-weight  for  height  or  over-size  for  age, 
all  three  constituents  of  the  diet  should  be  re- 
duced proportionally,  the  normal  distribution 
of  calories  being  retained,  because  the  di- 
minished caloric  needs  for  growth  permit  a 
reduction  in  the  fat  and  protein  as  well  as 
in  the  total  requirement.  On  the  other  hand, 
when  a  child  is  uiider-size  for  age  or  under- 
weight for  height,  the  total  caloric  need  is 
greater  than  the  average  and  the  usual  dis- 
tribution of  calories  should  be  retained,  all 
the  constituents  of  the  diet  being  increased. 

The  ration  usually  considered  standard  for  usuai 
adults  consists  of  100  grams  of  fat,  400  grams  tributiou 
of  carbohydrate  and  100  grams  of  protein 
daily.    This  gives  a  distribution  of  the  total 
calories  as  follows:  fat  31  per  cent,  carbo- 
hydrate 55  per  cent  and  protein  14  per  cent. 


146 


POOD,   HEALTH  AND  GROWTH 


OhUdrui 
Heed  Mor* 
Fat  and 
ProUla 
thaade 
Adnlta 


German 

Schedules 

Low  in  Fat 

andHlgbln 

Carbo- 

hxdrat* 


Murlin  calculated  the  distribution  of  food 
taken  by  the  soldiers  in  our  army  camps  to  be, 
fat  30  per  cent,  carbohydrate  56  per  cent,  pro- 
tein 14  per  cent.  Neither  of  these  differs  very 
widely  from  the  average  for  children;  viz., 
35-50-15. 

The  evidence  already  presented  shows  that 
children  have  greater  needs  for  both  fat  and 
protein  than  have  adults ;  hence,  a  somewhat 
higher  proportion  of  fat  and  of  protein  should 
be  supplied  in  their  diet  than  is  allowed  in  the 
adult  ration. 

The  reports  published  by  other  authors  of 
actual  diets  taken  by  children  show,  as  would 
be  expected,  considerable  variation  in  the  per- 
centage distribution  of  the  calories.  In  most 
cases,  however,  the  protein  taken  ranges 
from  15  to  20  per  cent  of  the  total. 

The  greatest  variation  is  seen  in  the  per 
cent  of  fat  and  of  carbohydrate.  In  most  of 
the  German  schedules  the  proportion  of  fat 
is  considerably  lower  than  that  here  recom- 
mended. 

In  Camerer's  schedule  the  proportions  of 
the  different  constituents  of  the  diet  are 
varied  with  increasing  age.  He  recommends 
37  per  cent  of  the  calories  as  fat  at  one  year, 
but  reduces  the  allowance  gradually  to  23  per 
cent  at  five  years  of  age,  maintaining  this 


DISTRIBUTION   OF    CALORIES  147 

value  throughout  the  remainder  of  growth. 
This  reduction  in  fat  is  met  by  increasing  the 
calories  of  carbohydrate.  In  his  schedule 
the  proportion  of  carbohydrate  rises  from 
45  per  cent  of  the  calories  at  one  year  to  60 
per  cent  at  five  years  and  remains  at  this  fig- 
ure throughout  the  remainder  of  the  growth 
period.  His  protein  allowance  at  one  year 
supplies  18.5  per  cent  of  the  total  calories; 
the  proportion  is  diminished  to  17  per  cent 
at  five  years  and  remains  at  this  figure  dur- 
ing the  remainder  of  growth.  His  distribu- 
tion throughout  the  greater  part  of  the 
growth  period,  therefore,  may  be  expressed 
as  23-60-17. 

In  concluding  this  discussion,  emphasis 
should  be  placed  on  the  importance  of  the  bal- 
anced ration.  The  protein  need  of  the  grow- 
ing child  is  very  important  and  there  seems 
to  be  fairly  general  unanimity  as  to  the 
amount  needed.  All  evidence  seems  to  indi- 
cate that  when  15  per  cent  of  the  total  caloric  importance 
need  is  supplied  by  protein,  the  nutritive  J^^jj^ 
needs  in  protein  are  met.  The  amount  of  fat 
required  is  still  a  debated  question,  but  it 
seems  reasonable  and  desirable  to  give  as 
much  fat  as  protein  to  the  growing  child.  If 
the  amounts  of  fat  and  protein  taken  are 
equal,  the  protein  will  furnish  15  per  cent  of 


148  POOD,   HEALTH  AND   GROWTH 

the  required  calories  and  the  fat  about  35 
per  cent.  The  remaining  caloric  need,  that 
is,  50  per  cent  of  the  total  calories,  is  then 
to  be  supplied  by  carbohydrate. 

When  this  distribution  is  deviated  from 
to  any  marked  degree  and  for  long  periods, 
that  is,  when  what  seems  to  be  a  proper  bal- 
ance of  the  diet  is  disturbed,  various  unde- 
sirable results  may  follow.  If  much  less  fat 
is  allowed,  the  carbohydrate  intake  is  usually 
excessive  and  digestion  may  be  disturbed  in 
consequence.  If  the  fat  is  too  high,  the  nor- 
mal fat  tolerance  may  be  exceeded  and  diges- 
tion be  seriously  upset.  High  fat  with  high 
protein  forms  a  combination  tending  to  cause 
constipation.  Low  fat  with  high  carbohy- 
drate may  give  rise  to  diarrhoea. 

On  the  whole,  one  may  conclude  both  from 
theoretical  considerations  and  practical  ob- 
servation that  a  diet  in  which  the  fat  supplies 
35  per  cent  of  the  total  calories,  the  protein 
15  per  cent  and  the  carbohydrate  50  per  cent 
is  one  which  meets  the  nutritive  needs  of  the 
child  and  is  well  borne  by  the  digestive  or- 
gans ;  that  is,  it  is  a  well-balanced  ration, 


CHAPTER  rV 
Lectube  Foub 

Vitamines 

In  the  study  of  foods  and  nutrition  the  em- 
phasis has  changed  frequently  with  the  years. 
Formerly  foods  were  valued  according  to 
their  chemical  composition — the  amount  of 
fat,  protein,  carbohydrate  and  mineral  salts 
which  they  contained;  in  infant  nutrition  in- 
terest centered  in  the  proportions  in  which 
these  different  food  constituents  should  be 
given  in  the  diet.  A  few  years  later,  when 
the  energy  value  of  foods  was  better  under- 
stood, foods  were  valued  and  used  according 
to  the  calories  they  furnished. 

At  present  interest  in  nutrition  is  focussed 
upon  the  ''accessory  food  factors"  or  vita- 
mines.  As  this  is  one  of  the  newer  fields,  it  is 
not  surprising  that  it  is  absorbing  the  atten- 
tion of  most  of  those  interested  in  nutrition, 
especially  from  the  laboratory  point  of  view. 
It  is  because  the  field  of  investigation  is  so 
recent  and  the  results  which  have  been  ob- 
149 


150 


POOD,   HEALTH  AND  GROWTH 


served  in  the  studies  upon  animals,  either  by 
adding  or  withdrawing  vitamines  from  the 
diet,  are  so  dramatic  that  possibly  we  are  in 
danger  just  now  of  losing  our  perspective 
and  of  giving  too  little  thought  to  other  fac- 
tors in  nutrition  which  are  quite  as  impor- 
tant, possibly  even  of  more  importance  than 
the  vitamines.  Our  new  knowledge  does  not 
invalidate  the  old;  it  has,  however,  given  a 
new  point  of  view  and  this  is  of  great  im- 
portance. 

In  our  consideration  of  this  subject  we 
must  not  then  fall  into  the  error  of  thinking 
that  the  vitamine  content  of  food  is  really  the 
one  and  only  thing  that  matters.  This,  how- 
ever, is  the  impression  which  one  might  re- 
ceive from  a  survey  of  much  recent  litera- 
ture on  the  subject  of  nutrition. 

Nearly  all  the  laboratory  observations 
upon  \dtamines  have  been  made  by  men  who 
were  not  physicians ;  it  remains  for  the  phy- 
sician to  test,  in  their  application  to  human 
beings,  the  conclusions  which  have  been 
drawn  from  a  study  of  animals. 

My  principal  purpose  in  this  lecture  will 
be  to  discuss  the  bearing  of  the  facts  which 
the  laboratory  workers  have  demonstrated 
upon  the  problems  of  human  nutrition,  es- 
pecially the  nutrition  of  children. 


VITAMINES  151 

It  seems  strange  that  constituents  of  our 
diet  so  important  as  the  vitamines  should 
have  so  long  escaped  notice.  Although  physi- 
ologists have  had  suspicions  of  the  existence 
of  some  such  substances  for  a  long  time,  yet 
practically  all  our  definite  knowledge  regard-  ourKnowi- 
ing  them  is  a  matter  of  scarcely  more  than  viunSLe. 
the  last  eight  or  ten  years.  sl^t 

One  of  the  earliest  observations  that  there 
were  other  substances  besides  fat,  protein, 
carbohydrates  and  mineral  salts,  which  were 
indispensable  to  life,  w^as  that  of  Lunin,  a  Ger- 
man physiologist.  Forty  years  ago  while  in- 
vestigating the  importance  of  inorganic  salts 
in  the  food  he  discovered  that  while  mice 
would  live  for  months  in  health  upon  a  diet  of 
milk,  they  invariably  died  within  a  month  on 
a  ration  containing  what  were  supposed  to  be 
the  essential  ingredients  of  milk,  viz.,  casein, 
fat,  milk-sugar  and  salts.  His  conclusion  was 
that  there  must  exist  in  milk  some  other 
substances  which  were  indispensable  for 
life. 

Other  investigators  made  many  attempts 
from  time  to  time  to  keep  animals  alive  upon 
diets  of  pure  protein,  fat,  carbohydrates, 
salts  and  water,  but  they  were  invariably  un- 
successful when  these  substances  were  care- 
fully purified.    The  failure  was  variously  ex- 


152  POOD,   HEAX.TH  AND   QEOWTH 

plained  as  due  to  monotony  of  diet,  lack  of  ap- 
petite, absence  of  flavor  in  the  food,  etc. 

It  is  to  Hopkins,  Professor  of  Physiology 
at  Cambridge,  that  the  credit  belongs  for  first 
grasping  the  significance  of  these  other  diet- 
ary factors  and  clearly  stating  the  question. 
I  cannot  do  better  than  to  quote  the  conclu- 
sions from  his  experiments  which  were  pub- 
lished in  1906.    He  says : — 

No  animal  can  live  upon  a  mixture  of  pure  pro- 
tein, fat  and  carbohydrate,  even  with  the  addition 
of  mineral  salts.  The  animal  body  is  adjusted  to 
live  upon  plant  tissues  or  other  animals  and  these 
contain  countless  substances  other  than  proteins, 
carbohydrates  and  fat.  Physiological  evolution 
has  made  some  of  these  well  nigh  as  essential  as 
are  the  basal  constituents  of  diet.  .  .  .  The  field 
is  almost  unexplored;  only  it  is  certain  that  there 
are  many  minor  factors  in  all  diets  of  which  the 
body  takes  account. 

Funk  in  1911  while  investigating  the  sub- 
ject of  beri-beri  obtained  from  rice  polish- 
ings  a  substance  which  prevented  beri-beri 
and  also  the  polyneuritis  of  birds.  As  this 
substance  contained  nitrogen  he  concluded 
that  it  belonged  to  a  class  of  compounds 
known  as  the  amines;  as  it  was  essential  to 
life  he  called  it  a  vit-amine. 

In  1912  Hopkins  published  the  results  of 


VITAMINES 


153 


ADDITION  OF  MILK   TO  PURIFIED  FOODSTUFFS 

•••••••CMWTN    ON   railFIE*  OUT 

■■■n      ...  .     «|TN  see  MIU    lAIlT 


-W  0*T» 


Fig.  20,  from  Hopkins:  By  purified  foods  is  meant  a 
diet  which  consists  of  pure  fat,  protein  and  carbohydrate. 
The  upper  curve  shows  normal  growth  when  a  small  amount 
of  milk  was  added  to  such  a  diet ;  growth  continued  at  a 
diminishing  rate  for  about  two  weeks  after  the  milk  was 
omitted ;  then  ceased  and  soon  a  loss  in  weight  occurred. 
In  the  growth  represented  by  the  lower  curve  the  experiment 
is  reversed;  the  animal  continued  to  gain  for  about  ten  days 
after  the  deficient  diet  was  given,  and  then  lost  weight;  but 
upon  adding  the  milk  a  marked  growth  response  was  seen 
after  a  few  days  and  thereafter  a  normal  growth  continued. 


154 


POOD,   HEALTH  AND  GROWTH 


MUkOon- 

tAlned 

Somathing 

BesidM  the 

Common 

Food  Oon- 

sUtUMita 


Som«thiiig 
Essential, 
Associated 
■with  But- 
ter Fat 


a  series  of  investigations  extending  over  sev- 
eral years.  He  found  that  young  rats  fed 
upon  pure  caseinogen,  lard,  starch,  cane 
sugar  and  salts,  lived  and  grew  to  some  ex- 
tent if  these  constituents  were  used  in  a  crude 
state;  but  if  they  were  carefully  purified, 
growth  was  arrested  and  death  soon  followed, 
even  though  the  total  food  intake  was  suffi- 
cient. However,  he  observed  that  if  he  added 
to  these  purified  foodstuffs  a  very  small 
amount  of  milk,  the  animals  continued  healthy 
and  normal  growth  ensued  (Fig.  20).  His 
conclusion  was  that  the  substance  or  sub- 
stances added  in  the  milk  were  of  such  a  na- 
ture that  the  body  could  not  manufacture  or 
synthesise  them. 

Hopkins'  investigations  mark  the  begin- 
ning of  an  appreciation  of  the  importance  in 
nutrition  of  what  he  termed  the  "accessory 
food  factors."  His  experiments  were  re- 
peated by  many  laboratory  workers  in  dif- 
ferent parts  of  the  world. 

Osborne  and  ^lendel  of  New  Haven  con- 
firmed the  statements  that  growth  and  pro- 
longed maintenance  was  not  possible  in  rats 
fed  on  a  carefully  prepared  artificial  food 
mixture  in  which  fat  was  supplied  by  lard, 
but  that  the  decline  in  health  was  promptly 
arrested   when   butter   was   substituted   for 


VITAMINES  155 

lard.  They  later  found  that  the  active  sub- 
stance was  only  in  the  fat  fraction  of  butter. 
As  the  butter  used  was  free  from  nitrogen, 
phosphorus  or  anything  soluble  in  water,  they 
concluded  that  the  substance  could  not  be  the 
same  as  the  anti-beri-beri  factor  studied  by 
Funk.  Osborne  and  Mendel  further  showed 
that  the  substance  which  they  found  in  butter 
was  also  present  in  certain  other  fats — beef 
fat  and  cod  liver  oil — but  was  absent  in  fats 
of  vegetable  origin. 

Funk  and  Macallum  had  found  that  rats 
would  not  grow  upon  their  artificial  food  mix- 
tures, and  also  that  many  of  them  died  with  sometting 
symptoms  of  paralysis  which  they  considered  Si**  ySSt* 
analogous  to  the  polyneuritis  of  birds  (avian 
beri-beri).  With  this  theory  they  added  yeast 
to  their  artificial  food  mixture  and  an  imme- 
diate growth  response  was  the  result.  Their 
conclusion  was  that  the  growth-promoting 
factor  was  not  contained  in  fats,  but  in  yeast. 

The  experiments  of  McCoUum  and  Davis 
confirmed  the  observation  that  rats  which 
did  not  grow  upon  the  artificial  ration  grew 
when  a  substance  derived  from  butter  and 
eggs  and  soluble  in  ether  was  supplied.  They 
also  found  that  this  growth  was  not  obtained 
when  the  fat  in  the  diet  was  lard  or  vegetable 
oils. 


156  FOOD,   HEALTH  AND   GROWTH 

It  was  not  until  1915  that  the  existence  of 
Ne^U^^  two  separate  and  distinct  accessory  food  fac- 
oroJrui"*    tors  was  finally  settled  definitely.     One  of 

MDWTN  ON  DIETS  OCriClCNT  IN  VITAMINCS 

^■■KWrUTI    tllT 

tlW    liriCIIIT   n  TITtNIII    -f 


Fig.  21,  from  Osborne  and  Mendel,  shows  that  both  vita- 
mine  A  and  vitaniine  B  are  necessary  for  growth.  In  the 
curve  to  the  left,  normal  growth  of  rats  on  a  complete  diet  is 
represented.  In  the  first  part  of  the  second  cune  the  diet  is 
deficient  in  both  A  and  B  and  a  steady  loss  in  weight 
occurs;  this  is  not  checked  by  adding  vitamine  A;  but  when 
both  A  and  B  are  supplied  normal  growth  at  once  begins. 
This  growth  is  immediately  arrested  when  both  are  with- 
drawn from  the  diet.  In  the  third  curve  no  growth  occurs 
when  both  A  and  B  are  lacking  and  none  occurs  when  B 
alone  is  added,  but  growth  promptly  follows  when  both  A 
and  B  are  supplied. 


these  substances  was  soluble  in  fat  and  was 
removed  from  the  food  with  the  fat ;  the  other 
had  different  properties  and  was  soluble  in 
water.     Both  however  were  present  in  milk 


VITAMINES  157 

and  both  were  necessary  for  health  and 
growth  (Fig.  21).  McCollum  suggested  the 
names  **fat-soluble  A"  and  '* water-soluble 
B"  instead  of  vitamine  proposed  by  Funk. 
However,  the  term  vitamine  has  gained  such 
currency  both  in  popular  and  medical  liter- 
ature that  it  is  likely  to  be  permanent,  in  spite 
of  the  fact  that  it  is  generally  believed  to  be 
chemically  inexact.  Laboratory  workers  still 
speak  of  them  as  the  fat-soluble  A  and  wa- 
ter-soluble B,  or  use  the  more  convenient 
terms,  vitamine  A  and  vitamine  B. 

That  in  scurvy  also  we  had  to  do  with  a  con- 
dition brought  about  by  the  absence  from  the 
diet  of  an  accessorj^  food  substance,  has  been  scurry  duo 
made  clear  by  observations  upon  animals,  and  viuSie** 
also  that  this  factor  was  diiferent  from  both 
vitamine  A  and  vitamine  B. 

Scur\y  has  been  known  for  centuries,  es- 
pecially among  sailors,  and  was  ascribed  to 
cold  exposure,  sea  air  and  salt  meats,  sepa- 
rately or  in  combination.  Twenty  years  ago 
the  idea  that  scurvy  was  of  infectious  origin 
gained  wide  but  not  general  acceptance.  As 
early  as  1734  Bachstrom  correctly  attributed 
it  to  the  absence  from  tlio  diet  of  fresh  vege- 
tables and  fruits,  observing  that  these  articles 
would  not  only  prevent  but  would  cure 
scurvy. 


158  FOOD,    HEALTH  AND  GROWTH 

In  1895  Theobald  Smith,  then  at  Harvard, 
published  an  observation  made  upon  guinea 
pigs ;  that  when  green  food  was  withheld  from 
these  animals  and  a  diet  of  oats,  hay  and 
water  was  given,  a  disease  developed  char- 
acterised by  haemorrhages  into  the  different 
tissues,  chiefly  about  certain  joints,  which  if 
unchecked  was  fatal  in  about  four  weeks  af- 
ter the  green  food  was  omitted.  The  disease 
was  easily  and  regularly  brought  about  ex- 
perimentally. The  significance  of  this  ob- 
servation was  apparently  not  recognised  and 
the  condition  was  not  identified  with  human 
scurvy. 

In  1900  Axel  Hoist  of  Christiania  made 
the  independent  observation  that  if  guinea 
pigs  were  kept  upon  a  diet  of  grain  and  water 
they  developed  a  condition  comparable  in  all 
essential  features  to  scurvy  in  man.  He 
regarded  the  disease  as  scui*vy  and  conducted 
a  long  series  of  experiments  with  various 
diets  both  producing  and  curing  the  disease. 
The  disease  could  be  prevented  and  cured  by* 
the  addition  to  the  diet  of  cabbage,  dandelion, 
cranberries  and  various  other  substances. 

This  susceptibility  of  certain  small  animals 
to  scurvy  has  led  to  a  great  advance  in  our 
knowledge  of  this  disease.  It  has  been  pos- 
■ible  to  ascertain  not  only  the  different  arti- 


VITAMINES  159 

cles  of  food  which  would  prevent  it,  but  the 
relative    amounts    required    for   protection. 

For  the  last  five  or  six  years  it  has  been 
generally  accepted  that  scurvy  was  a  defi- 
ciency disease  due  to  the  absence  from  the 
food  of  a  definite  factor  or  vitamine.  This  is 
conveniently  designated  vitamine  C. 

It  is  now  recognised  that  there  are  at  least 
three  accessory  food  factors,  each  of  which 
has  a  perfectly  definite  and  distinct  function 
in  human  nutrition,  and  that  all  of  them  are 
necessary  for  health  and  growth.  During  the 
last  few  years  our  knowledge  regarding  these 
factors  has  rapidly  increased  as  to  their  dis-  THr** 

.,        .  .  .  Dlstiiict 

tribution  in  the  various  foodstuffs,  also  how  viuminea 

Known 

they  may  be  injured  or  destroyed  by  the  vari- 
ous methods  of  preparing  or  preserving  food, 
the  sjTuptoms  which  are  produced  in  experi- 
mental animals  when  they  are  withheld  from 
the  diet,  and  the  different  clinical  conditions 
in  human  beings  with  which  each  of  these  sub- 
stances is  more  or  less  definitely  associated. 
The  fat-soluble  or  vitamine  A  was  first  de- 
tected in  butter-fat  and  Qgg  yolk  and  these 
foods  are  rich  sources.  It  is,  however,  very 
widely  distributed  among  foodstuffs.  It  is 
present  in  abundance  in  most  animal  fats  ex-  viumineA 
cept  lard,  also  in  heart,  liver  and  kidney  tis- 
sues, many  fish  oils,  especially  cod  liver  oil, 


160 


FOOD,   HEALTH  AND  GROWTH 


in  which  it  is  particularly  abundant.  Vege- 
table oils,  such  as  linseed,  olive,  cottonseed, 
com  oil,  etc.,  contain  practically  none  (Fig. 
22).  It  is  present  in  green  or  leafy  vege- 
tables, such  as  cabbage,  lettuce,  spinach,  also 


DCnCIENCY  OF  VITAMiNE  'A'  IN  TESCTABLC  OILS 


■•mri  •■  tiiT  ar  noii  aiw 

.  MINMIt   MIU 


u»  uism  IK 

MJ«I    tti 


Fig.  22,  from  Osborne  and  Mendel,  shows  that  while  rats 
make  a  normal  growth  upon  whole  milk,  they  make  very 
little  growth  upon  skimmed  milk  alone,  or  upon  skimmed 
milk  when  additional  fat  is  supplied  by  either  linseed  oil 
or  olive  oil.  The  longer  the  feeding  experiment  was  con- 
tinued the  more  evident  was  the  diet  deficiency. 

in  alfalfa  and  clover  and  other  grasses,  in 
sweet  potato  and  carrots  but  not  in  any  ap- 
preciable amount  in  white  potato  and  beets 
or  mangels.  Nearly  all  observers  agree  that 
vitamine  A  is  stable  to  the  ordinary  heat 
used  in  cooking. 

When  this  vitamine  is  withdrawn  from  the 


VITAMINES  161 

diet  symptoms  do  not  soon  appear.  From 
this  fact  the  conclusion  is  drawn  that  it  can 
be  stored  up  in  the  body,  probably  mth  the  wff^*r"' 
fat.  Fully  grown  rats  can  be  deprived  of  Ab'.en^. 
it  iwmetimes  for  months  without  showing  wrt  ^* 
definite  sjnnptoms  of  failing  nutrition;  but 
this  is  not  the  case  with  young  animals.  Usu- 
ally :n  a  few  weeks  evidences  of  this  defi- 
ciency begin  to  show  themselves.  Vitamine  A 
seems  therefore  to  be  much  more  important 
for  growth  than  for  maintenance.  By  some 
it  has  been  designated  the  growth  factor.  It 
is,  however,  true  that  the  other  vitamines  are 
also  necessary  for  growth,  though  their  ef- 
fects are  shown  in  different  ways;  for  man 
and  probably  for  most  animals  all  three  are 
indispensable.  Since  the  animal  body  cannot 
manufacture  them,  this  vitamine  as  well  as 
the  other  two  must  be  supplied  in  the  food. 
Exactly  what  is  the  function  of  vitamine 
A  in  nutrition  we  do  not  yet  know.  Young 
experimental  animals,  usually  rats,  whose 
food  is  deficient  in  this  factor,  in  a  few  weeks 
cease  to  grow  and  soon  begin  to  show  other  o/'^iStiB 
signs  of  imperfect  nutrition,  the  most  strik- 
ing evidence  of  which  is  an  inflammation  of 
the  eyes  which  begins  with  swelling  of  the 
lids  and  conjunctival  infection.  If  the  diet 
is  unchanged  the  process  goes  on  to  ulcera- 


162  FOOD,   HEALTH   AND  GROWTH 

tion  of  the  cornea  and  complete  destruction 
of  the  eye.  This  condition  is  known  as  xer- 
ophthalmia. If  before  serious  structural 
changes  in  the  eye  have  been  produced,  a 
ver\"  small  amount  of  butter,  cod  liver  oil, 
egg  yolk,  or  any  substance  rich  in  vitamine  A 
is  added  to  the  diet,  improvement  begins  im- 
mediately and  in  a  surprisingly  short  time 
without  other  treatment  the  eye  is  well  This 
occurs  so  regularly  that  it  must  be  regarded 
as  a  specific  action. 

Sooner  or  later  all  animals  in  whose  diet 
no  vitamine  A  is  supplied  decline  markedly 
in  general  health  and  the  death  rate  is  high. 
They  show  feeble  resistance  to  bacterial  in- 
fections, especially  of  the  lungs. 

A  diet  deficient  in  this  factor  produces  in 
young  dogs  after  several  months  bony 
changes  which  arc  apparently  identical  with 
those  of  rickets.  Mellanby  from  his  study 
of  these  changes  would  include  rickets  as  a 
deficiency  disease,  the  specific  cause  of  which 
is  the  absence  of  vitamine  A.  This  view  is 
not  generally  accepted. 

The  precise  role  of  vitamine  A  in  the  hu- 
man diet  is  little  understood.  Opportunities 
to  obser^'e  the  effects  of  its  complete  or  al- 
most complete  removal  from  the  diet  have 
been  very  limited.  In  nearly  all  cases  in  which 


VITAMINES  163 

this  vitamine  has  been  deficient  in  the  diet 
other  deficiencies  have  also  existed,  which' 
make  definite  conclusions  from  clinical  ob- 
servations diflficult.     Such  observations  are,  certain 
however,  interesting  and  strongly  suggestive.  in^Siudnm 
There  has  been  observed  in  infants  and  young 
children  suffering  from  serious  disorders  of 
nutrition,  particularly  when  living  in  institu- 
tions, a  disease  of  the  eye,  called  herato-ma- 
lacia,  which  closely  resembles  the  xerophthal- 
mia occurring  in  rats  and  which  is  probably 
identical  with  it. 

In  1904,  before  vitamine  A  was  known,  Mori 
described  a  disease  of  this  kind  seen  in  Japan. 
The  diet  of  the  children  observed,  who  were 
from  two  to  five  years  old,  was  chiefly  carbo- 
hydrates w^ith  a  small  amount  of  vegetable. 
Mori  attributed  the  condition  to  a  lack  of  fat 
in  the  diet.  He  found  in  cod  liver  oil  a  spe- 
cific remedy.  It  is  interesting  to  note  his  ob- 
servation that  the  condition  could  also  be 
prevented  by  chicken  livers,  cod  liver  oil 
and  other  fish  oils. 

More  recently  Bloch  of  Copenhagen  has 
reported  in  two  series  of  cases  a  similar  dis- 
ease observed  in  infants  who  were  hospital 
or  asylum  inmates.  In  the  first  series  the 
general  nutrition  of  all  the  infants  was  very 
poor.     The  diet  was  deficient  in  fat,  as  the 


164  FOOD,   HEALTH  AND   GROWTH 

infants  were  receiving  only  separated  milk. 
Without  other  changes  in  the  food  than  the 
addition  of  cod  liver  oil  the  eyes  began  to 
improve  almost  immediately  and  in  eight 
Au  Cured  days  were  %vell.  Improvement  also  occurred 
SvSoii  when  whole  milk  was  substituted  for  the 
skimmed  milk,  but  was  much  more  rapid 
when  cod  liver  oil  was  added.  In  some  cases, 
w^here  the  disease  was  far  advanced  before 
treatment  was  begun,  loss  of  sight  occurred. 
The  second  series  of  cases  were  observed 
later  in  a  home  containing  thirty-two  healthy 
children.  One  group  of  sixteen  got  no  milk ; 
the  only  fat  in  the  diet  was  a  margarine  made 
from  vegetable  oils.  Eight  of  these  children 
developed  kerato-malacia.  The  sixteen  in 
another  w^ard  received  whole  milk  as  a  part 
of  their  regular  diet.  Among  them  no  cases 
of  the  eye  disease  occurred.  The  difference 
in  the  diet  of  the  two  groups  was  simply  the 
whim  of  the  nurse  in  charge.  The  cases  were 
all  cured  by  cod  liver  oil.  Bloch  regarded 
the  condition  as  a  specific  one  due  to  a  de- 
ficiency of  vitamine  A. 

Ross  has  recently  reported  four  cases  of 
kerato-malacia  observed  in  Baltimore.  All 
were  in  marantic  infants  and  the  food  in  all 
instances  had  been  condensed  milk.  Three 
died  from  the  general  condition  shortly  after 


Otber  Dli- 


VITAMINES  165 

admission.  The  fourth  recovered  with  the 
administration  of  cod  liver  oil  and  a  change 
of  food,  first  to  whole  cow's  milk  and  later  to 
woman's  milk. 

Czemy  and  Keller  described  more  than  fif- 
teen years  ago  a  disease  in  young  children,  to 
which  they  gave  the  name  Mehlndhrschaden; 
a  condition  produced  in  their  opinion  by  a  tribuu/to 
diet  excessive  in  carbohydrates  and  lacking  vitinineA 
in  fat.  Kerato-malacia  was  one  of  the  char- 
acteristic symptoms. 

During  the  war  there  was  observed  both 
in  adults  and  children,  in  districts  where  food 
was  scarce  and  fats  almost  unobtainable,  a 
dropsical  condition  usually  called  ''war  or 
famine  oedema"  which  was  attributed  to  ab- 
sence of  fats  from  the  diet.  It  is  thought 
probable  that  this  was  due  to  lack  of  vita- 
mine  A. 

There  is  frequently  seen  in  hospitals  in 
marantic  infants  and  in  those  suffering  from 
severe  digestive  disorders,  on  account  of 
which  the  diet  has  been  greatly  restricted,  a 
form  of  general  dropsy  most  often  described 
under  the  term,  nutritional  oedema,  which 
possibly  is  to  bo  connected  witli  the  absence 
of  this  vitamine.  It  is  seen  when  on  account 
of  fat  intolerance  the  food  consists  almost  en- 
tirely of  carbohydrates  and  protein. 


166 


FOOD,   HEALTH  AND  GEOWTH 


It  is  to  the  excess  of  carbohydrate  in  the 
diet  that  the  condition  has  been  frequently 
attributed.  I  have  seen  it  develop  when  there 
was  no  such  excess  but  only  a  starvation  diet. 
In  one  instance  an  infant  of  three  or  four 
months  had  had  for  many  weeks  only  bariey 
water  for  food.  In  my  hospital  practice  the 
most  successful  dietetic  treatment  of  nutri- 
tional oedema  has  been,  next  to  woman's  milk, 
protein  milk,  which  though  low  in  carbohy- 
drates is  relatively  high  in  fat.  It  is  inter- 
esting also  to  note  that  several  of  Bloch's 
cases  of  kerato-malacia  also  had  general 
oedema. 

In  none  of  these  clinical  conditions  except 
possibly  kerato-malacia  can  one  state  with 
certainty  that  the  diet  deficiency  in  vitamine 
A  was  the  essential  cause.  Other  factors  of 
possible  importance  were  present  in  prac- 
tically all  of  them,  the  most  common  one  being 
a  very  low  food  intake.  Some  adults  with 
war  oedema  had  been  getting  but  800  calories 
a  day,  the  usual  allowance  for  a  baby  of  ten 
or  eleven  months. 

The  clinical  observations  referred  to  indi- 
cate how  difficult  it  is  to  draw  conclusions 
in  conditions  of  this  kind  from  a  study  of 
human  beings,  and  what  a  large  number  of 
cases  must  be  critically  studied  before  a  point 


VITAMINES  167 

can  be  definitely  established.  In  feeding  ani- 
mals in  the  laboratory  the  conditions  can  be 
controlled,  the  effects  of  a  single  diet  defi- 
ciency studied  at  one  time,  so  that  exact  and 
definite  results  can  often  be  established  from 
a  comparatively  small  number  of  experi- 
mental observations.  It  is  for  this  reason 
that  more  definite  additions  have  been  made 
to  our  knowledge  of  the  value  of  different 
foods  during  the  last  ten  years  by  laboratory 
methods  of  investigation  than  in  the  previous 
fifty. 

During  the  last  few  years  the  fat  in  the  food 
has  by  many  pa?diatrists  been  regarded  in  in- 
fant feeding  as  the  constituent  of  milk  most 
likely  to  do  harm,  and  a  reduction  of  the  fat 
considered  almost  the  first  duty  in  any  dis- 
turbance of  nutrition.  But  it  should  be 
known  that  this  practice  has  its  dangers.  It 
is  my  own  belief  and  experience  that  this 
practice  has  gone  much  too  far  and  that  in 
escaping  some  dangers  that  we  knew  we  have 
flo\\Ti  to  others  which  we  knew  not  of. 

Retuniing  to  the  subject  of  rickets,  it  may 
be  said  that  the  question  of  its  exact  causa- 
tion is  not  yet  settled.    It  has  long  been  be-  JJovm  dSI 
lieved  from  clinical  evidence  that  a  most  im-  cauw^ 
portant,  perhaps  the  most  important,  etio- 
logical factor  was  a  deficiency  of  fat  in  the 


168  FOOD,    HEALTH   AND   GROWTH 

diet.  Mellanby  has  produced  rickets  in  dogs 
by  diets  deficient  in  certain  animal  fats  and 
believes  that  the  antirachitic  food  factor  and 
vitamine  A  are  identical  substances. 

Paton  and  Watson  conclude  from  their  ex- 
perimental observations  that  a  liberal  allow- 
ance of  milk  fat  neither  prevents  nor  cures 
rickets  in  laboratory  dogs,  even  when  given 
in  such  large  amounts  as  14  grams  per  kila 
of  body  weight ;  but  if  the  animals  are  kept  in 
the  open  country  they  escape  rickets  on  an 
allowance  of  less  than  one  gram  per  kilo. 

Young  puppies  kept  in  the  country  on  a 
fat-poor  diet  escaped  rickets;  while  animals 
of  the  same  litter  kept  in  the  laboratory  and 
given  a  fat-rich  diet  developed  rickets.  Even 
laboratory-  animals  did  not  develop  rickets  on 
a  low-fat  diet  provided  they  were  given  par- 
ticular care  and  provided  also  the  diet  was 
in  other  respects  adequate. 

In  the  experience  of  many  observers  milk 
neither  prevents  nor  cures  rickets  in  children. 
That  there  is  a  special  antirachitic  food  fac- 
tor and  that  this  is  the  same  as  vitamine  A 
has  not  been  established.  "With  our  present 
knowledge  it  seems  highly  improbable. 

While  it  is  evident  that  in  the  causation  of 
rickets  diet  is  an  important  factor  it  seems 


VITAMINES  169 

altogether  probable  that  more  than  one  diet- 
ary factor  exists.  Environment,  especially 
one  which  affects  the  amount  of  sunlight,  is 
also  a  factor  of  much  importance,  since  in  a 
bad  environment  small  diet  deficiencies  may 
produce  the  disease  while  in  a  good  environ- 
ment they  may  not  do  so. 

The  water-soluble  or  vitamine  B  is  now 
considered  identical  with  the  antineuritis  vi-  viumineB 
tamine.     It  cures  the  polyneuritis  of  birds  orains. ' 

^      ''  .  Vegetables 

which  can  be  produced  by  a  diet  of  polished  widTeast 
rice.  It  is  very  widely  distributed,  being 
found  in  almost  all  the  foodstuffs  examined, 
although  in  widely  varying  amounts.  It  is 
abundant  in  yeast,  eggs,  most  meats,  espe- 
cially in  the  glandular  organs,  in  all  seeds  and 
grains,  in  the  latter  chiefly  in  the  germ  and  in 
bran,  in  nearly  all  vegetables,  especially  in 
potato,  spinach,  cabbage,  carrots,  turnips,  in 
nearly  all  fruit  juices,  particularly  orange, 
lemon  and  grapefruit,  in  nuts  and  finally  in 
milk.  The  potato  is  an  important  source  of 
this  vitamine  in  common  diets.  No  difference 
has  been  found  between  whole  or  peeled  po- 
tatoes, or  between  new  and  old  potatoes. 

In  the  accompanying  chart  (Fig.  23)  are 
shown  results  of  some  experiments  upon  the 
growth  of  rats  by  Osborne  and  Mendel  in 
which  vitamine  B  was  supplied  by  different 


170  FOOD,   HEALTH  AND  GROWTH 

im  fnmac  t  from  oifrcBcir  plaits 

m  ■^■■■■■■■■^■iM  MMM 


3fin 


31M 


1^ 


3« 


344 


1^ 


331 


317 


Mun 


HHHUMMS  HMmmttmM 

C3»  l=3«4       -  -      -        - 


Fig.  23,  from  experiments  of  Osborne  and  Mendel,  shows 
the  relative  value  of  different  plant  foods  with  respect  to 
the  amount  of  vitamine  B  which  they  contain.  The  normal 
gain  of  a  rat  during  eight  weeks  on  a  complete  diet 
is  90  grams.  When  vitamine  B  is  supplied  by  alfalfa  or 
clover  the  gain  is  nearly  twice  the  average,  if  one  gram  is 
added;  and  even  exceeds  the  average  when  only  one-half 
gram  is  added.  It  is  evident  from  the  chart  that  spinach 
is  nearly  twice,  and  tomato  is  more  than  twice,  as  valuable 
as  potato  in  the  same  quantities.  The  vegetable  food  given 
in  every  case  was  in  a  dry  powdered  form. 


foods,  and  shows  their  relative  value  as 
sources  of  this  vitamine.  The  columns  ^ive 
the  average  ,c:ain  of  the  animals  in  eight 
weeks ;  the  solid  black  column  when  one  gram 


VITAMINES  171 

of  the  vegetable  food  was  given  daily;  the  | 

white  column,  with  one-half  gram.     At  the  ' 

top  is  given  the  average  growth  of  normal  EtSwinui* 
healthy  rats  on  their  usual  food.     Alfalfa  ^^eT* 
and  clover  stand  at  the  head  and  tomato  next.  *'°°'*^ 
There  is  little  difference  between  cabbage, 
turnip    and    spinach.      Practically    normal 
growth  was  obtained  with  each  of  these  with 
one  gram,  but  not  with  one-half  gram.    With 
potato  fair  growth  with  one  gram,  almost 
none  with  one-half  gram. 

Vitamine  B  is  present  in  yeast  in  greatest 
concentration,  more  in  brewer's  than  in 
baker's  yeast.  The  ordinary  heat  of  cooking 
does  not  affect  it  to  any  important  degree,  nor 
does  drying,  whether  applied  to  eggs  or  vege- 
tables. It  is  removed  from  wheat  in  the 
process  of  milling,  being  practically  absent 
from  white  wheat  flour  and  from  polished 
rice.  It  is  present  in  whole  wheat  flour,  in 
wheat  bran  and  in  whole  rice  grains. 

When  this  factor,  vitamine  B,  is  removed 
from  the  diet  of  young  rats  and  mice  the  ef- 
fect is  seen  almost  immediately.  Within  a 
few  days  appetite  fails,  growth  ceases  and 
soon  a  decline  in  the  general  nutrition  is  evi- 
dent, which  continues  with  increasing  sever- 
ity until  the  animal  succumbs,  young  rats  in- 
variably in  less  than  eight  days.      In  many 


172  FOOD,    HEALTH  AND  GROWTH 

rats  and  dogs  there  is  seen  a  degree  of  mus- 
cular incoordination  and  weakness  amounting 
almost  to  paralysis.  If  to  such  animals  or  to 
birds  similarly  affected,  a  food  rich  in  the 
water-soluble  vitamine,  such  as  yeast,  is 
given,  no  matter  in  what  manner,  an  improve- 
ment that  is  marvelous  occurs  in  a  few  hours. 
Frequently,  after  a  single  feeding,  appetite 
returns  and  animals  before  almost  helpless 
are  able  to  run  about  and  birds  to  fly  as  if 
nothing  had  been  the  matter.  The  rapidity 
with  which  the  sjTuptoms  are  produced  and 
cured  is  in  striking  contrast  to  those  asso- 
ciated with  the  withdrawal  or  administration 
of  vitamine  A.  It  would  appear  that  the  ani- 
mal has  no  reserve  to  draw  upon,  so  that  vita- 
mine B  must  be  given  continuously  or  nutri- 
tion is  disturbed. 

What  the  function  of  this  accessory  factor 
in  normal  nutrition  is,  we  do  not  know.  That 
it  is  as  essential  to  man  as  to  animals,  clini- 
cal experience  abundantly  proves.  Long  be- 
fore the  existence  of  such  substances  as  those 
we  are  considering  was  suspected,  the  dis- 
ease beri-beri  was  connected  with  certain  diet 
deficiencies.  Beri-beri  is  a  very  common  con- 
dition in  certain  parts  of  Asia,  but  rarely 
seen  in  this  country.  As  early  as  1897  the 
association  of  beri-beri  with  a  diet  deficiency 


VITAMINES  173 

was  observed  by  Eijkman  in  a  prison  in  Java 
where  the  food  was  largely  polished  rice.  He  Beri.b«ri 
noted  also  that  poultry  fed  upon  rice  refuse  k^owS*!)!!- 
from  the  table  developed  paralysis  much  like  ^c^  "" 
that  seen  in  his  prisoners  with  beri-beri.  The 
condition  was  cured  by  the  administration  of 
rice  polishings,  or  an  alcoholic  extract  of 
them.  Vordermann  made,  Eijkman  states,  an 
exhaustive  study  of  all  the  prisons  in  Java 
and  found  that  everywhere  the  occurrence  of 
beri-beri  was  in  direct  proportion  to  the  ex- 
tent to  which  highly  milled  rice  was  used  as  a 
food.  In  the  prison  diet  the  other  articles  of 
food  were  for  the  most  part  poor  in  this  vi- 
tamine.  The  connection  between  beri-beri 
and  the  use  of  polished  rice  as  a  staple  article 
of  food  has  been  noted  by  many  observers  in 
different  parts  of  the  world. 

The  use  of  a  limited  diet  in  which  bread 
from  white  wheat  flour  forais  a  very  large 
part,  has  also  been  followed  by  similar  symp- 
toms, although  not  usually  so  severe  in  de- 
gree. In  Labrador  and  Newfoundland  beri- 
beri was  unknown  when  bread  was  made  from 
whole  wheat  flour.  Since  the  introduction  of 
white  flour  it  has  become  a  frequent  disease 
and  is  prevented  chiefly  by  the  consumption 
of  potatoes.  When  the  supply  of  potatoes 
fails,  outbreaks  of  beri-beri  are  common.  The 


174  POOD,   HEALTH   AND   GROWTH 

same  thing  has  been  witnessed  in  Ireland 
during  a  potato  famine. 

Hoist  states  that  in  Norway  great  sympa- 
thy was  aroused  for  the  hard  lot  and  poor 
food  of  the  sailors,  and  in  1894  in  response 
to  public  agitation  shipmasters  were  com- 
pelled to  supply  sailors  with  bread  made  from 
white  wheat  flour  or  wheat  and  rye  flour. 
After  this  went  into  effect  beri-beri,  unknown 
when  their  bread  was  made  from  whole  rye 
flour,  became  a  frequent  disease. 

The  British  Army  reports  contain  some  in- 
teresting facts  bearing  upon  this  subject. 
During  the  siege  of  Kut-el-Amara  in  the  re- 
Bul:?BrMd  ^^^^^  'wsiT,  beri-bcri  occurred  among  the  Brit- 
ish soldiers  who  received  white  bread  but  not 
among  the  Indian  troops  whose  bread  was 
made  from  a  coarse  whole  wheat  flour.  At  a 
later  stage  of  the  siege,  when  the  supply  of 
white  flour  was  exhausted  and  the  British  sol- 
diers were  compelled  to  eat  the  coarse  bread 
of  the  Indian  troops,  the  development  of  beri- 
beri ceased. 

When  the  diet  of  the  mother  is  lacking  in 
this  food  factor,  her  milk  is  also  deficient.  It 
is  reported  that  among  the  Filipinos  beri- 
beri is  common  among  the  nursing  children  of 
rice-eating  mothers  of  those  islands.  This  is 
believed  to  be  a  large  factor  in  the  extremely 


Ko  Bert-beri 


VITAMINES  175 

high  infant  mortality  which  is  seen  there. 

The  wide  distribution  of  vitamine  B  in  our 
common  foods  makes  it  improbable  that 
under  normal  peace  conditions  either  adults 
or  children  suffer  from  a  deficiency  of  this 
in  their  ordinary  diet,  particularly  since  cook- 
ing and  drying  do  not  destroy  nor  greatly  in- 
jure it. 

The  antiscorbutic  or  vitamine  C  differs  in 
some  very  important  particulars  from  the  Jj^^jj 
two  which  have  just  been  considered.  It  is  yiuSJo 
the  only  one  of  the  vitamines  that  is  especially 
sensitive  to  heat.  Certain  animals,  e.g.,  rats 
and  dogs,  have  generally  been  regarded  as 
not  susceptible  to  scurvy,  i.e.,  not  requiring 
this  vitamine  for  health  and  growth.  The 
recent  experiments  of  Harden,  Zilva,  and  of 
Drummond  at  the  Lister  Institute  throw 
doubt  upon  this  belief  in  the  case  of  rats  at 
least.  They  state  that  while  upon  a  scorbutic 
diet  these  animals  gain  weight,  grow  and  even 
reproduce  and  show  no  definite  symptoms  for 
months,  yet  they  do  not  thrive  as  well  as  ani- 
mals which  get  the  antiscorbutic  vitamine. 

More  es:tended  investigations  and  more 
carefully  conducted  experiments  have  shown 
in  the  case  of  each  one  of  the  vitamines  that 
they  were  present,  frequently  to  be  sure  in 
very  small  amounts,  in  many  foodstuffs  from 


176 


FOOD,    HEALTH   AND   GROWTH 


which  they  were  supposed  to  be  entirely  ab- 
sent. This  and  the  very  small  needs  of  some 
animals  may  be  the  explanation  of  the  appar- 
ent insusceptibility  to  scurvy. 

Further  investigations  are  certainly  nec- 
essary before  we  can  regard  it  as  definitely 
established  that  certain  animals  do  not  re- 
quire vitamine  C. 

This  vitamine  is  found  chiefly  in  fruits  and 
vegetables.  It  is  very  abundant  in  the 
orange,  lemon  and  grapefruit  but  curiously 
not  in  the  lime,  and  there  is  none  whatever 
in  the  preserved  lime  juice.  Cabbage  and  to- 
mato are  especially  rich  sources,  also  the 
swede  (yellow  turnip).  There  is  a  moderate 
amount  of  this  vitamine  in  potato,  in  the 
green  vegetables,  in  fresh  meat  and  a  small 
amount  in  milk.  Cereal  grains  have  none; 
but  Frohlich  has  discovered  that  if  grains  are 
moistened  and  allowed  to  germinate  for  a 
few  days  the  antiscorbutic  substance  is  de- 
veloped. 

A  particular  interest  in  this  connection  at- 
taches to  the  preparation  and  preservation 
of  the  food,  since  this  vitamine  is  nearly  al- 
ways injured  and  may  be  destroyed  by  heat, 
either  that  used  for  cooking  or  for  the  preser- 
vation of  foods.  The  amount  of  injuiy  done 
is  in  some  cases  very  well  known ;  in  others,  it 


VITAMINES  177 

is  still  a  matter  of  debate.  Canned  vege- 
tables (string  beans  and  cabbage  have  been 
especially  studied)  lose,  according  to  the  ex- 
periments of  Chick  and  Campbell,  from  70 
to  90  per  cent  of  their  antiscorbutic  potency. 
A  still  further  loss  occurs  from  storage,  so 
that  their  value  when  used  is  practically  nil. 
Cabbage,  boiled  for  one-half  hour  either  with 
or  without  the  addition  of  acid  or  alkali,  is 
still  an  efficient  antiscorbutic  but  has  lost 
about  four-fifths  of  its  value.  Dried  cabbage 
and  dried  tomato  retain  much  of  their  vita- 
mine;  dried  fruits,  a  sm.all  amount. 

Canned  tomatoes  are  an  efificient  antiscor- 
butic, but  must  be  given  in  somewhat  larger 
amounts  than  fresh  tomatoes.  It  has  been 
found  that  foods  which  are  kept  in  sealed 
containers  retain  their  vitamines  longer  than 
those  in  open  packages ;  this  is  attributed  in 
part  to  prevention  of  oxidation. 

In  dried  orange  and  lemon  juice  the  vita- 
mine  is  very  slightly  if  at  all  impaired  and 
when  kept  in  sealed  packages  they  retain 
their  antiscorbutic  activity  indefinitely.  I 
have  cured  scurvy  in  infants  with  dried 
orange  juice  that  had  b^en  kept  in  a  sealed 
package  for  over  one  year.  It  appeared  to 
be  quite  as  efficient  as  the  equivalent  amount 
of  the  fresh  juice. 


178 


POOD,   HEALTH  AND  GROWTH 


Dried  Vege- 
UbiM  of 

Ko  V&laa 


Amotmt  of 
Vltamlne  0 
In  Milk 
ia  Sm&ll 


That  dried  vegetables  are  practically 
valueless  as  antiscorbutics  was  slio%vn  as  long 
ago  as  the  Crimean  War,  and  the  observa- 
tions have  been  confirmed  in  all  the  subse- 
quent wars  in  which  they  have  been  tried. 

Fresh  meats  are  antiscorbutic  if  the 
amount  taken  is  liberal.  Arctic  explorers 
have  subsisted  for  months  with  no  other 
source  of  this  vitamine  in  their  diet  and  have 
been  free  from  scurvy.  But  this  is  not  true 
of  canned  meats;  they  are  practically  with- 
out antiscorbutic  value.  The  British  sol- 
diers while  besieged  in  Kut  ate  freely  of 
fresh  horse  flesh  and  escaped  scurvy ;  the  In- 
dian troops,  however,  who  are  vegetarians, 
suffered  severely  from  it,  as  they  could  get 
no  fresh  vegetables. 

From  the  point  of  view  of  the  nutrition  of 
children,  the  chief  interest  attaching  to  the 
effect  of  heat  upon  vitamine  C  relates  to 
the  heating  of  milk.  In  the  first  place  it 
should  be  understood  that  the  amount  of  this 
vitamine  in  fresh  milk  is  very  small.  How 
small  may  be  appreciated  by  the  fact  that 
Chick  and  Hume  found  that  to  protect  a 
guinea  pig,  whose  food  contains  no  other 
source  of  this  vitamine,  100  c.c.  daily  of  fresh 
milk  are  required,  although  complete  pro- 
tection is  secured  by  1.5  c.c.  of  orange  juice. 


VITAMINES  179 

It  is  well  established  that  all  heating  of 
milk  (I  do  not,  of  course,  mean  warming  for 
feeding)  whether  by  boiling,  pasteurising, 
sterilising,  drying  or  condensing,  injures  this 
\atamine,  though  it  does  not  seem  to  affect 
either  the  vitamine  A  or  vitamine  B.  The 
amount  of  injury  done  to  the  antiscorbutic  vi- 
tamine depends  upon  the  height  of  the  tem- 
perature and  the  length  of  the  period  during 
which  the  temperature  is  maintained,  and  Hwtog*' 
possibly  upon  whether  the  heating  is  done  in 
open  or  sealed  vessels.  The  duration  of  the 
heating  seems  clearly  quite  as  important  as 
the  temperature  employed.  Short  heating  at 
a  high  temperature  apparently  does  much  less 
injury  than  prolonged  heating  at  a  lower  tem- 
perature ;  so  far  as  its  effect  on  the  vitamine 
is  concerned,  boiling  for  five  or  ten  minutes 
seems  less  harmful  than  pasteurising  for 
thirty  minutes. 

While  there  is  still  considerable  difference 
of  opinion  among  investigators  as  to  the  rela- 
tive amount  of  damage  done  by  various  tji^es 
of  heating,  it  may  be  regarded  as  proven 
that  they  all  injure  milk  in  this  respect  to  ^^^utica 
some  degree  and  that  the  only  safe  rule  in  ^irilfflits' 
practice  is  to  supply  some  efficient  antiscorlni-  HeludMUk 
tic  in  the  diet  of  all  infants  reared  upon  milk 
treated  in  any  one  of  these  ways. 


180  POOD,    HEALTH  AND   GROWTH 

The  time  when  it  is  necessary  to  begin  fruit 
juice  or  other  antiscorbutic  will  be  influenced 
by  the  incubation  of  scurvy,  i.e.,  the  time 
when  symptoms  appear  after  the  scorbutic 
diet  is  used. 

In  the  guinea  pig,  which  is  one  of  the  most 
susceptible  animals,  sjTuptoms  of  scurvy  reg- 
ularly begin  after  about  three  weeks.  The 
monkej",  a  rather  less  susceptible  animal, 
shows  symptoms  of  scurvy  after  about  three 
months.  Hoist  and  Frohlich  mention  the  case 
of  a  fanatical  vegetarian  who  undertook  to 
live  upon  bread  and  water  and  who  developed 
symptoms  of  scur^^y  after  seven  and  a  half 
incnbation  mouths.  They  give  the  storj^  of  a  Russian 
refugee  who  was  confined  ^^ith  1400  others  in 
a  Russian  prison  where  the  diet  consisted  of 
bread,  tea  and  a  cabbage  soup.  This  soup 
was  so  filthy  in  appearance  that  he  and  about 
twenty  other  refined  people  simply  could  not 
eat  it.  In  about  six  months  he  and  his  group 
developed  scurvy.  The  rest  of  the  inmates 
who  took  the  soup  did  not. 

Definite  symptoms  of  infantile  scurvy  are 
most  frequently  seen  from  the  seventh  to  the 
tenth  month  of  age,  rarely  earlier  than  the 
sixth  month,  and  even  the  indefinite  symp- 
toms of  scorbutic  malnutrition  seldom  more 
than  a  few  weeks  before  this  time. 


VITAMINES  181 

In  my  own  clinical  experience  when  the  sole 
food  has  been  pasteurised  or  sterilised  milk,  u.uSy^** 
symptoms  of  scurvy  do  not  usually  appear  U^t** 
until  this  diet  has  been  continued  for  from  **<"^**" 
five  to  eight  months.    Of  the  last  nine  cases 
of  infantile   scurvy  treated  in  my  hospital 
service,  the  period  was  between  five  and  seven 
months  in  seven  cases  and  in  none  more  than 
nine  months.    Evidently  the  body  has  a  suffi- 
cient store  of  this  \dtamine  to  meet  its  needs 
for  a  considerable  period;  when  this  is  ex- 
hausted symptoms  appear.    If  the  food  con- 
tains even  a  small  amount  of  vitamine  C,  the 
development  of  scurvy  will  be  delayed. 

To  infants  whose  principal  or  sole  food  is 
any  one  of  the  forms  of  heated,  dried  or  con- 
densed milk,  it  would  appear  then  to  be  quite 
sufficient  if  an  antiscorbutic  wore  ])ogun  at 
the  age  of  four  or  five  months,  although  there 
is  no  objection  to  giving  it  at  an  earlier 
age. 

As  to  the  amount  of  the  vitamine  required 
we  have  no  very  definite  knowledge;  al- 
though the  relative  value  of  different  foods 
as  antiscorbutics  has  boon  pretty  well  deter- 
mined by  Chick  and  Hume  (Fig.  24).  Ac- 
cording to  their  experiments  the  susceptible 
guinea  pig  needs  daily  for  complete  protec- 
tion about  100  c.c.  of  fresh  cow's  milk  or  1.5 


182  FOOD,   HEALTH  AND  GROWTH 

c.c.  of  orange  juice;  that  is,  orange  juice  is 
about  sixty  times  as  potent  an  antiscorbutic 
as  is  fresh  cow's  milk.  The  monkey,  whose 
weight  is  about  ten  times  as  great,  requires 
only  about  twice  as  much  of  either  for  protec- 


KEOeO  TO  PREVniT  SCURVY  IN  OHMEA  KfiS 


■lai 

caoiu  cuiui      ^^mtm 
ions  ^i^iM 


■iW  TMUn 

CiMHT  jmet 
tmua  nun 

KtTMCT  jma 


ua  HUT  mta 
aa  taf%  nu 


In  Fig.  24,  based  upon  experiments  of  Chick  and  Hume 
of  the  Lister  Institute,  are  shown  the  relative  richness  of 
common  articles  of  food  in  vitamine  C.  Tomato,  cabbage, 
orange  and  lemon  juice  stand  at  the  top;  of  these  only  one 
gram  or  1.5  c.c.  respectively,  are  needed  for  protection, 
while  of  fresh  cow's  milk  which  stands  at  the  bottom  more 
than  100  c.c.  is  needed. 

tion  as  does  the  guinea  pig.  If  the  human  in- 
fant were  as  susceptible  as  the  guinea  pig 
there  would  be  needed  weight  for  weight 
about  two  quarts  of  fresh  milk  daily,  or  one 
ounce  of  orange  juice,  at  the  age  when  scurvy 


VITAMINES  183 

is  most  often  seen.  Practically  we  find  that 
those  who  get  even  somewhat  less  than  one 
quart  of  fresh  cow's  milk  very  seldom  de- 
velop scurvy.  It  would  seem  then  that  15  c.c. 
or  half  an  ounce  of  orange  juice  daily  was, 
under  average  conditions,  ample  for  protec- 
tion in  the  latter  half  of  the  first  year. 

Of  the  common  antiscorbutic  foods,  orange 
juice  is  undoubtedly  the  best,  but  is  some- 
what expensive  and  not  always  obtainable. 
The  dried  orange  juice,  not  yet  on  the  general 
market,  seems  almost  if  not  quite  as  effective 
and  does  not  lose  its  activity  by  keeping. 
Dried  orange  and  lemon  juice  seem  likely  to 
prove  some  of  our  most  convenient  anti- 
scorbutics. 

I  have  had  no  personal  experience  with  the 
juice  of  the  swede  but  the  experiments  of 
Chick  and  Hume  at  the  Lister  Institute  indi-  „  ^    ,  ^ 

other  Antl- 

cate  that  this  is  quite  as  eifective  as  orange  scorbutici 
juice  in  the  same  quantities.    It  is  grated  and 
the  juice  squeezed  out  in  a  cloth  by  hand. 

The  juice  of  fresh  raw  or  canned  tomatoes 
is  cheap  and  effective  as  an  antiscorbutic.  It 
is  perhaps  a  little  more  likely  to  disturb  the 
digestion  than  is  orange  juice,  but  can  be 
given  to  most  infants  without  any  difficulty. 
I  have  found  it  effective  both  in  preventing 
and  in  curing  scurvy,  but  it  nmst  bo  given  in 


184 


FOOD,    HEAIiTH  AND   GROWTH 


somewhat  larger  doses  than  orange  juice  and 
the  seeds  carefully  strained  out. 

Are  there  conditions  present  in  disease, 
particularly  of  the  digestive  tract,  which  may 
interfere  w^th  either  the  absorption  or  the 
activity  of  vitamines,  so  that  the  conse- 
quences of  a  deficiency  may  exist  even  though 
these  substances  may  be  given  in  the  food  in 
adequate  amounts?  We  do  not  yet  know. 
But  so  far  as  the  vitamine  C  is  concerned  this 
seems  not  improbable,  particularly  in  diar- 
rhoeal  conditions.  All  who  have  seen  much 
of  infantile  scurvy  know  the  difficulties  in 
treatment  when  diarrhoea  is  present  or  is 
easily  excited.  Of  course  diarrhoea  may  be 
present  as  one  of  the  symptoms  of  the 
scurvy.  A  concentration  of  the  vitamine  by 
removing  from  orange  or  lemon  juice  all  the 
vegetable  acids  has  been  used  by  Chick  and 
Still  in  such  cases  as  these  with  most  satis- 
factory results,  without  causing  any  disturb- 
ance of  the  bowels.  AVitli  this  concentrated 
preparation  much  larger  amounts  could  be 
administered  and  very  prompt  cure  effected. 

I  have  myself  seen  scurvy  develop  in  a 
hospital  patient  while  under  observation  and 
while  taking  as  much  as  30  c.c.  of  orange 
juice  daily.  In  this  case  no  acute  diarrhoea 
was  present  but  there   did   exist  a  serious 


VITAMINES  185 

chronic  disturtance  of  digestion  with  a  tend- 
ency to  looseness  of  the  bowels. 

Future  investigations  may  reveal  the  fact 
that  vitamine  deficiency  is  a  cause,  which  we 
do  not  now  suspect,  of  some  of  the  symptoms 
seen  in  certain  chronic  diseases.  This  is  less 
likely  to  be  the  case  in  acute  disease  as  it  is 
so  long  before  effects  of  deficiencies  in  vita- 
mine  A  or  vitamine  C  are  evident. 

While  we  have  learned  a  great  deal  regard- 
ing what  vitamines  do,  we  know  very  little  ^***g°'^ 
else  about  them.  None  of  them  has  as  yet  been  ^Jj^**- 
isolated.  The  effect  of  heat  upon  vitamine  A  ^°®* 
has  not  been  definitely  settled.  Hopkins* 
recent  experiments  with  butter  fat  indicate 
that  heat  in  sealed  vessels  does  not  injure  the 
vitamine  even  though  prolonged  and  the  tem- 
perature high,  while  moderate  heat  with  aera- 
tion destroys  it ;  also  that  if  butter  is  exposed 
to  the  air  in  thin  layers  for  long  periods  it 
loses  its  vitamine.  The  inference  is  that  it  is 
destroyed  by  oxidation.  Most  experiments 
indicate  that  this  vitamine  is  stable  to  ordi- 
nary heat  used  in  cooking  unless  the  heat  is 
very  prolonged. 

Vitamine  A  is  soluble  in  alcohol  and  ether. 
Osborne  and  Mendel  have  extracted  with 
ether  from  the  green  leaves  of  plants,  using 
spinach,  clover,  alfalfa,  an  oily  substance  with 


186 


FOOD,   HEALTH  AND  GROWTH 


which  they  secured  growth  quite  equal  to  that 
obtained  mth  butter  fat. 

Vitamine  B,  now  generally  regarded  as 
identical  with  the  antineuritic  vitamine,  is 
soluble  in  water  but  not  in  alcohol  or  ether. 
It  is  unaffected  by  ordinary  temperatures 
used  in  baking  or  boiling,  but  may  be  injured 
by  prolonged  heating  at  high  temperatures. 
Osborne  and  Wakeman  succeeded  in  concen- 
trating the  vitamine  from  brewer's  yeast  but 
not  in  isolating  it. 

Vitamine  C  is  soluble  in  water  and  alcohol 
and  passes  through  porcelain  filters.  From 
the  fact  that  acid  fruit  juices  retain  their 
value  much  longer  than  vegetable  juices, 
Hoist  concludes  that  the  antiscorbutic  vi- 
tamine is  more  stable  in  acid  than  in  neutral 
media.  Harden  and  Zilva  have  sho^\^l  that 
it  is  rapidly  destroyed  at  room  temperature 
by  dilute  alkalies.  Oxidation  seems  also  to 
injure  it. 

I  have  already  alluded  to  the  fact  that  the 
animal  body  cannot  manufacture  or  synthe- 
sise  vitamines.  They  are  constant  body  needs 
and  must  be  taken  in  continually  with  the 
food.  The  belief  at  present  is  that  they  are 
synthesised  in  plants;  the  herbivorous  ani- 
mals get  them  from  plants,  the  camivora  from 
the  herbivora. 


VITAMINES  187 

Hart,  Steenbock  and  Ellis  have  made  the 
important  observation,  since  confirmed  by 
others,  that  the  vitamine  content  of  cow's 
milk  is  affected  by  the  food  of  the  animal. 
This  was  first  shown  to  be  true  of  the  anti- 
scorbutic vitamine.  The  winter  milk  of  stall- 
fed  animals  was  decidedly  poorer  in  this  re- 
spect than  the  summer  milk  of  pastured  ani- 
mals. 

From  investigations  made  by  others  this 
same  law  seems  to  apply  to  all  the  vitamines.  S.^p^^^ 
If  the  food  of  the  cow  does  not  contain  an  J^jjj^ 
adequate  supply,  the  milk  may  be  deficient 
in  any  or  in  all  of  them. 

The  same  rule  applies  to  the  nursing 
mother.  This  may  furnish  a  clue  to  some  of 
the  puzzling  cases  of  scurvy  developing  in 
nursing  infants.  It  may  also  explain  why 
infants  do  not  thrive  upon  some  milks,  al- 
though the  supply  is  abundant  and  the  pro- 
portion of  the  different  constituents,  as 
shown  by  chemical  analysis,  is  within  the  nor- 
mal range. 

The    important    practical    application    of  Essenti&i 
these  facts  is,  first,  to  recognise  the  necessity  J,"  Cursing 
of  supplying  to  nursing  mothers  a  diet  whicli  ^o^*'" 
is  ample  in  all  the  vitamines.  Vitamine  C  and 
vitamine  A  are  the  ones  most  likely  to  be  lack- 
ing in  the  diet  of  the  poor.    These  are  abuu- 


188  FOOD,    HEALTH  AND   GROWTH 

dantly  supplied  by  milk,  eggs,  green  vege- 
tables and  fruits,  all  of  which  unfortunately 
are  expensive  foods,  but  they  should  be  in- 
cluded in  the  diet. 

It  would  seem  in  the  diet  of  children,  par- 
ticularly infants,  a  \nse  precaution  during 
the  winter  to  supplement  cow's  milk  by  other 
foods  knowTi  to  be  rich  in  vitamine  A,  such  as 
butter,  the  yolk  of  egg  or  the  juice  of  steamed 
green  vegetables,  but  best  of  all  by  cod  liver 
oil;  small  doses  will  probably  suffice,  i.e.,  a 
half  teaspoonful  of  the  pure  oil  daily  for  an 
infant  of  nine  or  ten  months  of  age.  Defi- 
ciency of  vitamine  C  in  winter  milk,  which 
may  exist  even  though  milk  has  not  been 
heated,  should  be  corrected  by  giving  orange 
or  tomato  juice. 

Our  knowiedge  of  vitamines  is  as  yet  only 
partial  and  very  incomplete.  "\Ve  are  really 
only  at  the  beginning  of  a  line  of  research  in 
nutrition  which  has  possibilities  we  can 
hardly  foresee.  Constant  additions  are  be- 
ing made  to  our  knowledge;  and  many  things 
generally  accepted  one  or  two  years  ago  are 
now  show'n  to  be  erroneous. 

Scientific  research  along  any  line  is  diffi- 
cult; the  pitfalls  for  the  untrained  and  inex- 
perienced are  numerous,  and  it  is  not  sur- 
prisiiicr   that   many   premature    and   unwar- 


VITAMINES  189 

ranted  conclusions  have  been  drawn  from 
laboratory  observations  in  the  investigation 
of  vitamines. 

One  of  the  early  errors  was  due  to  the  fact 
that  the  purified  foodstuffs  composing  the  so- 
called  "basal  diet"  supposed  to  be  free  from  J^™^"^^ 
vitamines  were  not  pure.  Vitamines  exist  in 
food  in  very  small  quantities,  and  some  arti- 
cles which  were  long  believed  to  contain  none 
have  been  shown  to  have  enough,  if  large 
amounts  of  the  food  in  question  are  taken,  to 
vitiate  the  result  of  an  experiment.  Or,  take 
the  question  of  the  amount  of  milk  required  to 
maintain  growth.  Equally  good  obsei'v^ers 
have  gotten  quite  contrary  results  in  their  ex- 
periments. We  now  know  that  the  vitamine 
content  of  milk  is  not  constant  but  varies  with 
the  food  of  the  animal. 

Lard  has  been  regarded  as  the  one  notable 
exception  to  the  rule  that  animal  fats  are 
rich  in  vitamine  A.  The  process  used  in  re- 
fining commercial  lard,  however,  is  in  all  es- 
sential features  identical  with  the  process 
which  Hopkins  has  recently  shown  to  be  de- 
structive to  vitamine  A  in  butter.  Its  absence 
therefore  from  lard  seems  to  bo  explained  by 
the  process  used  in  its  yireparation. 

Again,  when  orange  juice  was  added  to  the 
diet,    the    effects    which    followed    were    at- 


190 


FOOD,    HEALTH   AND   GROWTH 


tributed  to  the  antiscorbutic  vitamine.  But 
Osborne  and  Mendel  have  sho^vn  that  this 
and  some  other  fruit  juices  are  also  rich  in 
vitamine  B  and  even  contain  some  vita- 
mine  A. 

We  are  constantly  learning  how  widely  dis- 
tributed the  vitamines  are  in  all  natural  food- 
stuffs, but  may  be  injured  by  methods  of  prep- 
aration. Alilk  contains  much  vitamine  A,  a 
moderate  amount  of  vitamine  B  and  some  vi- 
tamine C.  Tomato,  cabbage  and  many  other 
green  leafy  vegetables  contain  all  the  vita- 
mines.  The  potato  has  considerable  of  vita- 
mine B  and  vitamine  C  and  even  some  vita- 
mine A.  Even  cod  liver  oil,  the  rich  source 
of  vitamine  A,  contains  many  other  sub- 
stances which  may  profoundly  affect  nutri- 
tion. 

It  seems  quite  evident  that  until  these  sub- 
stances which  we  call  vitamines  have  been 
isolated,  the  interpretation  of  experiments 
along  this  line  is  open  to  error.  Clearly,  until 
this  has  been  accomplished  many  of  our  con- 
clusions from  animal  experiments  must  be 
regarded  as  tentative  only. 

Again,  there  is  a  risk  in  drawing  too 
sweeping  inferences  from  the  results  of  ex- 
periments upon  small  animals.  Almost  all 
the  observations   thus  far  have  been  made 


VITAMINES  191 

Mpon  rats  and  guinea  pigs.  "We  have  already 
seen  in  the  case  of  scurvy  that  the  suscepti- 
bility of  different  species  of  animals  to  a  de- 
ficiency in  vitamine  C  differs  enormously. 
This  may  also  be  found  to  be  true  of  the  other 
vitamines  also. 

The  great  service  thus  far  rendered  in  the  J^J^^^i^ 
study  of  vitamines  has  been  twofold :  first,  it  vaiuw* 
has  given  a  new  basis  for  the  evaluation  of 
foods,  and  secondly,  it  has  sho^\^l  what  dam- 
age may  be  done  to  natural  foods  by  the  meas- 
ures employed  in  refining  or  preserving 
them. 

Out  of  the  searching  examination  to  which 
all  our  foods  have  been  subjected,  two, 
hitherto  much  neglected  and  often  placed  at 
the  foot  of  the  class,  have  emerged  with  high 
honours,  viz.,  the  cabbage  and  the  tomato. 
These  and  other  articles  which  from  the  point 
of  view  of  their  energy  value  are  almost 
worthless  have  been  shown  to  possess  a  nu- 
tritive value  which  is  very  great.  They  fur-  chemicai 
nish  something  more  than  flavor  to  food,  to  ^es^Not 
make  it  more  appetising,  something  very  cs-  yl^nJ'*^^ 
sential  in  a  human  diet.  The  importance  of 
some  foods  in  diet  is  not  suggested  by  chem- 
ical analysis.  The  tomato,  cabbage,  spinach, 
lettuce,  chard  and  all  the  green  or  leafy  vege- 
tables are  composed  chiefly  of  cellulose,  water 


192 


FOOD,   HEALTH  AND   GROWTH 


and  inorganic  salts.  Fruits  have  sugar,  vege- 
table acids,  water  and  salts;  but  none  of 
these  things  suggest  their  essential  value  in 
diet. 

Many  of  our  foods  we  no  longer  eat  in  their 
natural  state.  The  conditions  of  modem  life 
have  made  necessary  the  transportation  of 
foods  for  long  distances  and  the  preservation 
and  storage  of  food  in  immense  quantities  for 
long  periods.  A  certain  amount  of  injury  is 
done  to  our  vegetables,  fruits,  milk,  meats  and 
grains  by  the  processes  to  which  they  are  sub- 
jected in  preparation,  preservation  and  stor- 
age. The  study  of  vitamines  has  helped  us  to 
understand,  to  some  degree  at  least,  the  na- 
ture of  the  harm  that  has  been  done.  Some  of 
this  occurs  from  the  heat  applied  during  our 
ordinary  processes  of  cooking ;  some  is  a  con- 
sequence of  heat  applied  for  purposes  of 
sterilisation,  whether  for  the  destruction  of 
the  germs  of  disease  or  for  the  preservation 
of  food  by  canning. 

Another  example  is  what  we  have  sacri- 
ficed in  their  nutritive  value  by  the  refinement 
of  our  foods,  as  in  polishing  rice  and  using 
only  the  white  flour  of  our  wheat  to  make  our 
bread,  feeding  to  pigs  and  cows  the  bal- 
ance of  the  grain.  The  coarse  black  bread  of 
the  Middle  Ages  and  of  the  European  peas- 


What  We 
Gain 


VITAMINES  193 

ant  of  today  is  despised  by  our  modem  civil- 
ised city  dweller. 

But  there  is  another  side  to  the  question; 
let  us  not  at  the  same  time  forget  the  immense 
benefits  of  the  preservation  and  storage  of 
food.  Take  for  example  the  question  of  white 
wheat  flour.  As  long  as  wheat  was  grown  and 
milled  in  this  countr^^,  as  it  still  is  in  most 
European  countries,  within  a  comparatively 
short  distance,  seldom  more  than  one  or  tw^o 
hundred  miles  of  where  it  was  consumed, 
and  was  used  wdthin  a  few  weeks  of  milling, 
the  problem  was  a  simple  one. 

At  present  much  of  our  milling  is  done  one 
or  two  thousand  miles  from  our  large  centres 
of  population.  Not  only  must  the  time  re- 
quired for  transportation  be  taken  into  ac- 
count, but  the  necessity  for  storage  of  very 
large  quantities  as  a  normal  food  reserve. 
New  York  City,  for  instance,  consumes  over 
20,000  barrels  of  flour  every  day.  Very  much 
of  this,  it  is  estimated,  has  been  milled  five  or 
six  months  before  it  is  consumed.  "WTiite 
wheat  flour  keeps  indefinitely,  certainly  for  wtoi« 
six  months,  without  any  important  deteriora-  Fiour*wm 
tion.  But  whole  wheat  flour  can  be  kept  only  Long 
about  thirty  days ;  after  tliat  it  is  likely  to  be- 
come ** wormy"  from  the  development  of  ova 
which  are  deposited  in  the  husk.    One  whole 


194 


FOOD,    HEALTH   AND  GROWTH 


cargo  of  1000  barrels  sent  to  Glasgow  during 
the  war  had  to  be  thrown  away  for  this 
reason. 

Flour  experts  tell  us  that  the  general  adop- 
tion of  whole  wheat  flour  for  bread  in  this 
country  is  an  economic  impossibility.  But 
the  modern  method  of  milling  and  our  system 
of  transportation  and  storage  make  a  bread 
famine  here  almost  impossible.  In  China, 
however,  without  facilities  either  for  trans- 
portation or  storage,  there  may  be  famine  in 
one  province  \vhen  wheat  is  abundant  and 
selhng,  Thos.  W.  Lamont  tells  us,  for  a  few 
cents  a  bushel  in  another  province. 

Although  heating  milk  may  injure  or  de- 
stroy its  antiscorbutic  vitamine,  this  fact  does 
not  invalidate  its  great  advantages,  such  as 
protection  from  diseases  which  may  be  com- 
municated through  milk,  and  the  preserva- 
tion of  milk  by  drying,  condensing  or  sterilis- 
ing which  permits  its  wider  use  as  a  food  all 
over  the  world. 

The  same  may  be  said  of  the  canning  and 
drying  of  vegetables,  fruits  and  eggs.  These 
preserved  foods  are  of  great  benefit  in  the 
nutrition  both  of  children  and  adults.  We 
could  not  stop  the  use  of  them  if  we  would, 
and  we  would  not  if  we  could. 

Our  present  knowledge  of  vitamiues  has 


VITAMINES  195 

pointed  out  that  these  same  procedures  have 
their  disadvantages,  even  their  dangers ;  but 
when  the  nature  of  these  is  once  thoroughly 
understood  and  their  importance  appreciated, 
the  remedy  will  come  also;  possibly  in  some 
improvement  in  the  processes  now  in  use,  or 
it  can  always  be  done  by  supplying  in  the  diet 
by  other  articles  of  food  the  particular  vi- 
tamine  which  has  been  injured  or  destroyed. 

The  food  of  infants  or  older  children  is  in 
normal  times  almost  never  lacking  in  vita- 
mine  B.  It  is  the  antiscorbutic  vitamine  only 
that  is  likely  to  be  injured  by  any  process  to 
which  their  food  is  subjected  in  preparation 
or  preservation.  But  I  have  never  seen  and 
have  never  known  of  a  case  of  scurvy  in  a 
child  over  two  years  old  who  was  living  under 
normal  peace  conditions.  So  far  as  vitamine 
A,  so  indispensable  for  the  growth  of  chil- 
dren, is  concerned,  it  is  necessary  only  that 
care  be  taken  that  the  diet  include  an  ample 
supply,  since  it  is  not  Ukely  to  be  injured  in 
the  preparation  or  preservation  of  food. 

We  know  well  the  dangers  of  vitamine  de- 
ficiency when  the  diet  is  necessarily  restricted  oonditionB 

because  conditions  do  not  admit  of  choice  or  mine  Defi- 
ciency Is 

variety  of  food.     These  conditions  exist  in  ^ik'^y 
times  of  famine,  or  great  food  shortage,  or 
even  may  be  the  result  of  poverty,  also  in 


196 


FOOD,    HEALTH   AND   GROWTH 


prisons,  army  camps,  on  ship-board,  in  Arctic 
regions  and,  one  must  add,  in  infancy. 

The  consequences  to  children  are  serious, 
whether  we  consider  simply  arrested  gro^vth 
and  general  malnutrition,  or  the  diseases 
like  scurvy  and  beri-beri,  which  result  from 
marked  and  prolonged  deficiencies.  But  it  is 
not  likely  that,  except  in  conditions  like  those 
mentioned,  cither  children  or  adults  who  take 
the  average  or  usual  diet  are  likely  to  receive 
such  small  quantities  of  the  vitamines  as  defi- 
nitely to  interfere  either  with  healthy  growth 
or  normal  nutrition. 

A  glance  over  the  list  of  foodstuffs  kno^vn 
to  contain  the  different  vitamines  shows  how 
abundant  vitamines  are  in  most  common 
foods.  This  may  be  one  of  the  reasons  why 
in  the  evolution  of  the  diet  of  the  human  race 
certain  foods  have  hold  their  place. 

It  seems  therefore  perfectly  evident  that 
unless  the  diet  given  is  a  very  one-sided  one, 
children  receive  in  their  usual  food  a  liberal 
supply  of  all  these  essential  food  constitu- 
ents. This  will  be  certain  to  be  the  case  if  the 
regular  diet  includes  milk,  green  vegetables, 
fruits  and  cereals. 

There  are  two  verj^  striking  things  brought 
out  in  the  investigation  of  vitamines  by  the 
observation  on  animals:  One  is  the  ver>'  small 


VITAMINES  197 

amounts  which  are  apparently  required  to 
produce  their  effects  and  the  other  is  the 
specificity  of  their  action.  Until  these  sub- 
stances have  been  isolated  we  shall  not  know 
the  amounts  required  for  normal  nutrition. 
Apparently  the  amount  of  any  one  of  them 
is  not  large. 

Chick,  Drummond  and  their  associates  at 
the  Lister  Institute  have  showTi  how  much  of 
different  foods  is  required  to  protect  labora- 
tory animals  against  beri-beri  and  also 
against  scurvy,  when  the  diet  contained  no 
other  source  of  the  vitaraine  in  question. 
They  determined,  for  example,  how  much  of 
orange  juice,  cabbage,  tomato  and  many  other 
foods  was  needed  to  prevent  scurvy ;  and  how 
much  of  potato,  yeast,  egg  and  many  other 
foods  was  needed  to  prevent  bori-beri. 

While  this  establishes  much  that  is  impor- 
tant with  regard  to  the  relative  value  of  cer- 
tain foods,  it  gives  us  no  idea  as  to  the  actual 
amounts  of  vitamine  required  by  human  be- 
ings. All  the  evidence  goes  to  show  that  the 
vitamine  requirement  is  affected  by  many 
conditions.  It  undoubtedly  varies  widely 
even  in  animals.  Laboratory  animals  in  con- 
finement might  be  expected  to  sliow  effects  of 
deficiencies  in  diet  sooner  than  those  living 
under  natural  conditions.    It  has  often  been 


198 


FOOD,    HEALTH  AND  GROWTH 


observed  that  men  who  were  much  exposed 
and  doing  hard  work  were  affected  by  scurvy 
sooner  than  others,  although  all  had  the  same 
diet.  If  the  human  diet  is  poor  in  other  re- 
spects the  effects  of  the  absence  of  the  anti- 
scorbutic or  any  other  vitamine  are  more 
quickly  apparent. 

How  much  of  the  different  vitamines  is 
needed  for  health  we  do  not  yet  know.  It  is 
clearly  not  a  definite  amount  for  all  human 
beings  of  the  same  age,  sex  and  weight,  but 
like  our  other  food  requirements  the  vitamine 
need  no  doubt  varies  with  many  conditions. 

The  special  importance  of  vitamines  for 
growth  makes  it  imperative  that  the  diet  of 
children  should  contain  the  articles  already 
enumerated  which  are  rich  in  these  factors. 
The  requirements  of  adults  are  for  mainte- 
nance merely  and  undoubtedly  are  much  less 
than  the  requirements  of  children.  This  is 
especially  true  of  vitamine  A. 

It  is  during  the  period  of  infancy  that  chil- 
dren are  likely  to  suffer  most;  first,  since 
infants  are  the  most  susceptible  of  human  be- 
ings to  all  adverse  conditions;  secondly  in- 
fancy is  the  period  of  most  rapid  growth  and 
anything  which  may  affect  growth  produces 
its  most  marked  effects  at  this  time ;  finally, 


VITAMINES  199 

the  diet  of  infancy  is  necessarily  a  restricted 
one. 

It  is  not  only  the  infant  who  is  artificially 
fed  who  may  suffer  from  vitamine  deficiency. 
The  mother  must  take  them  in  with  her  food 
if  she  is  to  give  them  out  in  her  milk.  This  is 
true  of  any  of  the  vitamines,  but  is  especially 
important  in  the  case  of  vitamine  A,  the  need 
of  which  seems  especially  marked  in  infancy. 

With  infants  who  are  fed  upon  cow's  milk 
we  are  rather  more  likely  to  see  evidences  of 
vitamine  deficiency  in  the  winter  or  early 
spring  months  than  in  summer  and  fall. 

Proprietary  infant  foods  are  dangerous 
not  so  much  from  what  they  contain  as  from 
what  they  lack.  They  may  be  deficient  in  all 
three  of  the  vitamines.  Cereals  have  practi- 
cally no  vitamine  A  or  vitamine  C,  and  the 
dangers  of  deficiency  are  likely  to  exist  just 
in  proportion  to  the  extent  to  which  they 
form  a  part  of  the  diet. 

The  specificity  of  action  of  these  substances 
is  quite  as  great  as  that  of  antitoxin  in  diph- 
theria or  thyroid  extract  in  cretinism.  The  J^ch  vitl- 
different  vitamines  seem  entirely  indepen-  I'^ciic 
dent  of  each  other  in  their  activity.  They  are 
in  no  way  interchangeable ;  tliey  seem  to  have 
no  relation  to  one  another.  We  cannot  sup- 
ply a  deficiency  in  vitamine  B  by  giving  more 


200 


FOOD,    HEALTH   AND   GROWTH 


of  vitamiiie  A,  nor  can  we  protect  against 
scurvy  by  the  most  liberal  allowance  of  vita- 
mine  B.  Each  one  has  a  perfectly  definite 
function  in  nutrition;  which,  from  evidence 
now  in  our  possession,  can  be  performed  by  it 
but  by  nothing  else.  If  no  vitamine  deficiency 
exists  in  the  diet,  it  does  not  seem  probable 
that  symptoms  of  malnutrition  will  be  im- 
proved by  giving  vitamines  in  excess;  it 
would  be  surprising  if  it  were  so,  and  we  lack 
evidence  that  such  is  the  case. 

Another  practical  question  is  whether  if 
the  diet  is  low  in  its  vitamine  content,  i.e.,  a 
condition  of  relative  deficiency  exists,  there 
may  occur,  perhaps  not  frank  scurvy,  beri- 
beri, or  kerato-malacia,  but  milder  and  less 
definite  symptoms,  such  as  failure  to  make 
normal  progress  in  growth,  malnutrition,  and 
general  evidence  of  ill  health.  This  is  some- 
thing difficult  to  establish.  On  a  priori 
grounds  it  seems  not  improbable.  It  must  be 
remembered,  however,  that  symptoms  such  as 
those  mentioned  may  be  due  to  a  great  variety 
of  causes  other  than  vitamine  deficiency.  In 
the  absence  of  definite  means  of  diagnosis  the 
only  evidence  of  tlieir  dependence  upon  vi- 
tamine deficiency  is  the  therapeutic  test,  viz., 
prompt  and  decided  improvement  which  fol- 
lows when  foods  known  to  be  especially  rich 


VITAMINES  201 

in  the  different  vitamines  are  added  to  the 
diet,  such  as  orange  juice  or  yeast  or  cod 
liver  oil. 

In  this  connection  one  is  reminded  of  the 
patent  medicine  advertisement  which  ran 
somewhat  as  follows:  **If  you  are  cured 
you  haven't  got  the  disease.  The  remedy 
never  fails." 

From  our  experience  with  deficiency  diets 
in  animals  positive  results  should  certainly 
be  seen  in  a  few  weeks.  Definite  results  in 
man  can  only  be  established  by  careful  clini- 
cal observations.  It  should  first  be  e\'ident 
from  an  analysis  of  the  diet  that  a  deficiency 
probably  exists.  The  changes  made  should 
be  as  carefully  planned  as  are  laboratory  ex- 
periments with  rats  or  guinea  pigs.  Other- 
^'ise  the  results  reported  to  follow  are  likely 
to  depend  upon  either  the  faith  or  the  skepti-  I 

cism  of  the  observer. 

Some    suggestive    observations    regarding  ^*^'^^foni 

the  use  of  antiscorbutic  vitamine  have  been  j^ijen  De- 
ficiency- 
made  by  Hess  and  others,  in  which  the  weight  ^*^^'^ 

curve  of  infants  showed  a  prompt  rise  on  the 
addition  of  orange  juice  to  the  daily  diet; 
but  in  many  or  most  of  those  cases  the  diet 
was  known  to  be,  or  at  least  strongly  sus- 
pected to  be,  poor  in  this  factor. 

Some  results  which  may  be  significant  have 


202 


FOOD,    HEALTH   AND   GROWTH 


also  been  seen  to  follow  the  use  of  cod  liver 
oil  in  certain  conditions  of  malnutrition  in  in- 
fancy, particularly  in  premature  infants.  I 
have  myself  seen  the  weight  curve  of  some 
premature  infants  who  had  made  no  gain  for 
many  days  show  an  immediate  rise  by  no 
other  change  than  the  addition  of  five  drops 
of  cod  liver  oil  to  the  daily  food.  It  con- 
tinued while  the  oil  was  administered  and 
ceased  when  it  was  withdrawn.  This  amount 
is  too  small  to  change  the  energy  value  of  the 
food.  The  effect  noted  looks  like  a  specific 
action.    It  is  certainly  suggestive. 

Vitamine  B  has  been  urged  upon  the  pro- 
fession in  the  form  of  yeast  as  being  espe- 
cially important  for  children  who  are  not 
making  the  normal  gain  in  weight,  who  suffer 
habitually  from  poor  appetite  and  chronic 
constipation,  etc.  In  the  discussion  at  the 
American  Paxiiatric  Society  meeting  in  Juhe, 
1921,  the  practically  unanimous  opinion  ex- 
pressed w^as  one  of  complete  disappointment 
in  results  obtained  and  incredulity  regarding 
the  specific  advantages  claimed. 

However,  in  view  of  the  important  part 
which  we  now  know  to  be  played  by  vitamines 
in  nutrition,  it  behooves  the  physician  in  all 
cases  of  malnutrition,  particularly  when  the 
explanation   is    not    obvious,   to   investigate 


VTTAMINES  203 

carefully  the  character  of  the  food  and  its 
preparation  to  discover  any  errors  which 
might  result  in  a  vitamine  deficiency.  Espe- 
cially is  this  necessary  in  the  case  of  chronic 
invalids,  or  of  delicate  children  whose  diet 
has  become  greatly  restricted  from  necessity 
or  from  caprice,  and  particularly  in  the  case  BenDntfrom 
of  infants  whose  diet  is  always  a  restricted  tion  wh.n' 
one.    But  until  we  have  some  more  certain  ciency  ex- 

.  ,  l8t«.  Very 

means  of  diagnosis  than  we  now  possess  the  Doubtful 
indiscriminate  use  of  vitamines  in  other  cir- 
cumstances than  the  above,  for  what  is  often 
referred  to  as  '^general  results,"  is  not  likely 
to  be  beneficial;  it  has  no  rational  basis;  it 
should  be  discouraged;  it  is  hardly  scientific 
therapeutics. 

It  is  most  unfortunate  that  the  popular  in- 
terest in  vitamines  which  is  the  result  of  so 
much  recent  publicity  as  has  been  given  to 
this  whole  subject,  should  be  exploited  com-  commercial 

•    11  T  •  •  •       o      ^  •  Explolta- 

mercially.  Just  now  vitamines  are  m  fashion  ^°^  trnfor- 
and  as  much  capital  as  possible  is  being  made 
of  this  fact.  The  medical  profession  at  all 
events  should  not  be  carried  along  in  the  pop- 
ular current.  Important  and  indispensable 
though  vitamines  are,  we  must  not  lose  sight 
of  the  fact  that  there  are  many  other  dietary 
factors  equally  important. 

The   physician   can   fall  into   no   greater 


204 


FOOD,   HEALTH   AND   GROWTH 


error  than  to  assume  that  vitamine  de- 
ficiency is  the  chief  cause  of  all  chronic 
nutritive  disorders;  just  as  not  very  long 
ago  these  were  all  referred  to  auto-intoxica- 
tion and  at  present  a  certain  group  would 
have  us  believe  that  they  are  due  to  some 
disturbance  of  the  glands  of  internal  secre- 
tion. The  use  of  vitamines  without  defi- 
nite indications  mil  be  popular  for  a  period 
but  like  other  fads  it  will  pass.  With  time 
and  further  investigation  their  true  place 
will  be  determined. 

Our  knowledge  of  vitamines  has  taught  the 
necessity  of  a  variety  of  food  and  the  danger 
which  follows  when  conditions  make  a  variety 
impossible.  It  has  taught  us  also  the  incom- 
parable value  of  certain  foods,  particularly  of 
milk,  not  only  in  infancy,  but  during  the  en- 
tire period  of  growth ;  also  the  importance  in 
the  diet  of  children  of  the  green  or  leafy  vege- 
tables. The  chief  objections  to  some  like  cab- 
bage, lettuce  and  celery,  when  used  in  a  raw 
state  is  the  diflQculty  of  making  children  mas- 
ticate them  properly. 

Our  knowledge  of  vitamines  has  greatly 
helped  to  put  the  whole  subject  of  nutrition 
upon  a  scientific  basis.  The  experimental 
method  has  been  substituted  for  the  empirical 
one  in  determining  the  value  of  the  different 


VITAMINES  205 

foods.  Formerly  we  might  know  that  cer- 
tain foods  were  desirable  or  necessary;  now 
we  are  able  in  very  many  cases  to  say  why 
such  is  the  case,  and  to  determine  their  pre- 
cise value  in  nutrition.  What  was  once  little 
more  than  a  suspicion  has  become  definite 
knowledge. 

The  discovery  of  the  role  of  vitamines  rep- 
resents another  milestone  passed  on  the  road 
of  scientific  progress.  It  has  furnished  the 
key  to  many  problems  which  were  before  ob- 
scure or  altogether  insoluble.  As  in  bacteri- 
ology and  immunology  it  is  the  work  of  the 
laboratory  which  has  made  advance  possible. 

The  part  contributed  by  the  rat — one  of 
man's  worst  enemies — is  a  very  large  and  im- 
portant one.  For  this  contribution  we  should 
perhaps  in  the  future  treat  him  with  more 
consideration. 

Until  confirmed  by  clinical  experience  there 
is  however  some  danger  in  relying  too  much 
upon  the  results  of  laboratory  observations 
upon  animals  of  different  species  whose 
physiological  needs  may  be  different  from 
those  of  human  beings. 

To    sum    up    the    whole    discussion:    The 
study  of  vitamines  has  taught  us  several  im-  summary 
portant   things    regarding   the   nutrition    of 
children : 


206  POOD,   HEALTH  AND  GROWTH 

I  That  children  should  eat  a  variety  of  food 
and  that  especial  dangers  may  follow  the 
habitual  use  of  a  very  restricted  diet. 

That  milk  is  the  one  indispensable  food  for 
children.  The  diet  during  the  entire  growth 
period  should  include  if  possible  whole  milk, 
or  if  skimmed  milk  is  used,  it  should  be  sup- 
plemented by  butter.  Of  the  butter  substi- 
tutes, those  which  contain  beef  fat,  mutton  fat 
and  peanut  oil  are  better  than  those  in  which 
other  vegetable  oils  or  lard  are  important 
constituents. 

How  much  milk  or  butter  is  required  to 
supply  the  amount  of  vitamine  A  needed  we 
do  not  know.  The  need  would  seem  to  be 
greatest  during  the  period  when  growth  is 
most  rapid.  From  our  present  knowledge  at 
least  a  pint  of  milk  a  day  seems  desirable. 

That  a  diet  which  includes  no  milk  what- 
ever should  contain  ample  amounts  of  the 
green  or  leafy  vegetables. 

Cereals,  particularly  those  from  whole 
grains  and  potato,  aro  important  and  ade- 
quate sources  of  vitamine  B. 

Fruits  have  other  uses  than  as  laxatives 
and  as  sources  of  mineral  salts;  they  should 
form  a  regular  part  of  the  diet. 

When  fresh  fruits  are  not  available  dried 
fruits  may  be  given,  but  they  are  distinctly  in- 


VITAMINES  207 

ferior  to  canned  tomatoes  as  sources  of  the 
antiscorbutic  vitamine. 

Cabbage  is  such  a  rich  source  of  all  the  vi- 
tamines  that  it  should  form  a  larger  part  of 
the  diet  than  is  usually  the  case,  especially 
since  it  is  cheap  and  in  winter  often  almost  oabbl^J 
the  only  green  vegetable  available.  Unless 
thoroughly  masticated  raw  cabbage  is  diffi- 
cult of  digestion  for  young  children.  Cab- 
bage when,  boiled  for  one-half  hour  undoubt- 
edly retains  enough  of  the  antiscorbutic  fac- 
tor for  the  needs  of  the  body.  Its  other  vita- 
mines  are  practically  uninjured. 

In  normal  peace  conditions  the  results  of 
vitamine  deficiencies  are  most  often  seen  in 
infancy;  very  rarely  in  older  children,  and 
then  only  in  extreme  poverty,  in  chronic  dis- 
ease or  in  rare  cases  of  very  delicate  children 
whose  diet  has  become  much  restricted. 

If  the  daily  diet  contains  milk,  cereals,  po-  EsBenu&n 
tato,  green  vegetables,  some  fruit,  one  need  cSii(Jin°' 
not  fear  a  \Ttamine  deficiency. 

While  these  articles  are  especially  rich  in 
vitamines,  most  of  our  common  foods  contain 
them. 


CHAPTER  V 

Lecture  Five 

Practical  Measures  for  Improving  the  Nutrition  of 
CMldren 

The  practical  importance  of  normal  nutri- 
tion to  the  child  is  very  great,  as  it  not  only 
affects  his  childhood  but  its  consequences 
reach  forward  into  adult  life.  We  have  come 
so  far  short  of  realising  what  is  possible  of 
accomplishment,  as  sho\\Ti  by  the  low  stand- 
ard of  health  and  nutrition  which  we  have 
permitted  to  exist  in  our  country  among  chil- 
dren, that  it  has  seemed  desirable  in  this  con- 
cluding lecture  to  consider  briefly  some  of  the 
means  by  which  the  present  situation  could 
be  improved,  applying  at  many  points  facts 
brought  out  in  previous  lectures. 

Is  it  possible,  is  it  practicable,  so  to  change 
conditions  which  affect  the  nutrition  and 
growth  of  the  children  of  tliis  country  as  to 
bring  about  a  material  improvement?  If  it 
is  possible  it  should  certainly  be  attempted, 
to  this  end  using  all  means  now  available  and 

208 


IGNORANCE  OF   THE  EDUCATED  209 

developing  new  and  better  ones  to  supple- 
ment those  we  have. 

The  greatest  agencies  for  promoting  re- 
form along  any  line  are  publicity  and  educa- 
tion.   This  is  particularly  true  of  all  health  Sl^orMt- 
matters.     The  public  must  first  understand  ***     ''^"^ 
and  appreciate  the  need  and  then  be  taught 
the  remedy  and  how  to  apply  it. 

In  this  effort  to  raise  the  standard  of  health 
in  children  we  have  to  combat  not  only  the 
ignorance  of  the  ignorant,  but  using  Chester 
ton's  striking  phrase,  the  *  ignorance  of  the 
educated."  People  may  be  intelligent  about 
almost  everything  else,  but  grossly  ignorant 
regarding  all  the  essential  rules  of  healthy 
living.  They  may  be  vn.se  in  all  other  practi 
cal  matters,  but  unspeakablv  foolish  with  re- 
spect to  their  children'^Qflpocihli)'  when  the 
subject  involves  discipline  and  training. 

To  improve  the  nutrition  of  our  children 
is  no  easy  task,  nor  will  the  ideal  be  reached 
in  one  generation,  but  groat  improvement  in 
conditions  can  be  brought  about  in  a  com- 
paratively short  time  by  well  organised  intel- 
ligent effort.  ^ 

Children  may  fail  to  attain  normal  physi- 
cal development  from  many  causes,  some  of  M\mu\rt-' 
which  like  a  bad  inheritance  or  premature  poorpifysi- 
birth  reach  far  back  and  the  consequences  of  opm?n7*'' 


210  FOOD,    HEALTH   AND  GROWTH 

which  can  never  be  wholly  overcome,  no  mat- 
ter what  the  subsequent  life  history  of  the  in- 
dividual. Other  causes  are  previous  acute 
or  chronic  illness  of  a  serious  nature.  In  still 
other  children  normal  nutrition  may  be  inter- 
fered with  by  certain  physical  defects,  such 
as  carious  teeth,  large  or  diseased  tonsils  or 
adenoids.  Failure  in  nutrition  also  may  be 
the  first  and  for  some  time  the  only  obvious 
symptom  of  the  development  of  some  serious 
disease  like  tuberculosis,  nephritis,  cardiac 
disease  or  grave  anaemia.  In  the  great  ma- 
jority of  cases,  how^ever,  children  are  below 
normal  vdih.  respect  to  their  nutrition  or  fail 
to  make  normal  progress  in  health  and  growth 
as  a  result  of  improper  or  insufiQcient  food 
and  faulty  hygiene. 

To  begin  ^^dth  the  food.    This  may  be  abun- 
dant but  lacking  in  the  essential  elements  for 
growth ;  what  these  are  has  already  been  con- 
sidered:   An  adequate  supply  of  high  grade 
rood  protein,  largely  from  animal  sources;  a  lib- 

eral amount  of  fat ;  an  ample  supply  of  min- 
eral salts  for  growth  of  bono ;  and  finally  the 
essential  vitamiiios.  All  these  constituents 
will  be  supplied  in  ample  amount  if  milk,  ce- 
reals, green  vegetables  and  fruit  in  reason- 
able quantities  form  a  part  of  the  regular 
diet;  but  they  are  not  furnished  in  a  diet 


Impropti 


CAUSES   OF   MALNUTRITION  211 

common  in  many  homes,  in  which  the  prin- 
cipal articles  are  coffee,  white  bread,  meat, 
potato  and  sweets.  The  cost  of  such  a  diet 
equals  and  often  exceeds  the  more  valuable 
one.  Insufficient  food  may  be  the  result  of 
economic  conditions — witness  the  numbers  of 
children  in  our  cities  who  go  to  school  with  no 
other  breakfast  than  bread  and  coffee,  and 
whose  principal  lunch  is  sweets  from  the 
pushcart.' 

Examples  of  bad  food  habits  are,  eating  at 
all  hours  rather  than  at  regular  hours;  the  S*v,T°°'*^ 

"  '  Habits  and 

consumption  of  sweets  and  trash  between  g*^'^, 
meals,  and  rapid  eating  \rith  little  mastica- 
tion of  food.  Faulty  hygiene  includes  over- 
crowding, lack  of  fresh  air  in  sleeping-rooms 
or  school-rooms  or  lack  of  opportunity  for 
out-door  play,  late  hours,  in  consequence  of 
which  the  child  never  gets  a  proper  allowance 
of  sleep,  and  seldom  an  opportunity  for  a  rest 
in  the  middle  of  the  day  after  the  age  of  three 
or  four  years.  Overactivity  in  the  form  of 
work  or  sometimes  in  play  consumes  so  much 
of  the  energy  value  of  the  food  that  little  or 
none  is  left  for  growth.  By  referring  to  the 
chart  on  page  74  it  will  be  observ'cd  that  if  the 
allowance  for  activity  is  greater  than  the 
average,  it  must  be  at  the  expense  of  growth 
unless  the  amount  of  food  taken  is  propor- 


212 


FOOD,    HEALTH   AND   GROWTH 


Waiglit  for 
Height 


Th*  Ar*r- 
ag«  and  tbe 

Korm&l  not 
th*  Same 


tionately  increased;  since  the  requirements 
for  basal  metabolism  and  the  loss  in  excreta 
cannot  be  reduced.  Even  habitually  bad  pos- 
ture is  a  factor  of  some  importance ;  as  is  also 
chronic  constipation  from  which  most  of  these 
children  suffer  in  consequence  of  lack  of  regu- 
larity in  habit.  There  are  a  great  many 
other  minor  causes  which  might  be  men- 
tioned, but  the  above  include  the  chief  ones. 

When  is  a  child  to  be  considered  under- 
nourished? When  is  one  to  be  considered 
w^ell  nourished,  one  might  wx'll  ask.  By  far 
the  best  guide  is  weight  in  relation  to  height. 
I  do  not  think  it  makes  any  essential  differ- 
erence  whether  we  use  the  standing  or  the 
sitting  height.  The  standing  height  without 
shoes  is  most  generally  used. 

The  average  is  not  the  normal  either  in 
weight  or  height.  The  average  is  a  line;  the 
normal  is  a  zone.  Neither  weight  for  age  nor 
height  for  age  is  of  much  value  in  determin- 
ing the  question  of  nutrition.  Both  are  sub- 
ject to  wide  variations  from  such  causes  as 
race,  family  inheritance,  etc.,  so  wide  indeed 
as  to  make  these  of  little  interest.  Certain 
deviations  from  the  average  even  of  weight 
for  height  are  compatible  with  good  health 
and  also  with  normal  nutrition.  How  wide 
the  variation  from  the  average  must  be,  to  be 


EVIDENCES  OF   MALNUTRITION  213 

placed  in  the  abnormal  group  is  an  arbitrary^ 
question  and  not  all  observers  agree.  The 
great  majority,  however,  have  considered  that 
if  any  child  under  twelve  years  old  is  less 
than  10  per  cent  or  more  below  or  20  per  cent 
above  average  weight  for  height,  he  may  be 
placed  in  the  normal  group,  so  far  as  his 
nutrition  is  concerned.  For  those  over  twelve 
years,  since  growth  during  the  adolescent 
period  is  more  irregular  than  at  an  earlier 
age,  a  slightly  wider  deviation  from  the  aver- 
age weight  for  height  may  be  included  in  the 
normal  group. 

But  not  every  child  whose  weight  is  proper  stunted 

.  .  .  J.        I-         ChUdren 

for  his  height  is  to  be  considered  normal. 
Sometimes  long  continued  bad  feeding  or 
underfeeding  may  result  in  children,  as  in 
laboratory  animals,  in  a  great  stunting  in 
size  as  well  as  in  weight.  The  child  may 
then  show  a  proper  relation  of  weight  to 
height  but  be  far  below  the  normal  in  both. 
Age,  therefore,  must  be  taken  into  account. 
Of  two  children  of  the  same  height  but  of  dif- 
ferent ages  the  older  should  be  the  heavier. 
Again,  there  are  quite  a  group  of  children 
who  are  not  as  much  as  ten  per  cent  below 
normal  weight  who  are  not  in  perfect  health 
and  who  may  require  attention  because  of 
teeth,  tonsils,  glandular  enlargements,  pos- 


214  FOOD,   HEALTH  AND   GROWTH 

ture,  etc.,  but  they  can  hardly  be  classed  as 
cases  of  malnutrition. 

The  other  important  evidence  of  improper 
nutrition  is  failure  to  gain  normally  in  weight. 
Observations  must  extend  over  a  consider- 
able period  before  this  can  be  determined. 
Few  children,  even  those  in  the  best  of  health, 
after  infancy  gain  regularly  every  month. 
Th^re  are  often  periods  of  two  or  three  months 
in  which  very  little  progress  is  recorded,  when 
no  cause  can  be  found  sufficient  to  explain  it. 
There  are  also  certain  seasonal  variations. 
The  gain  both  in  height  and  in  weight  is  usu- 
ally greater  from  June  to  December  than  from 
December  to  June.  But  a  stationary  weight 
for  a  prolonged  period  or  steady  loss  at  any 
time  is  a  warning  which  should  never  be  dis- 
regarded. Regular  periodical  weighings, 
usually  once  a  month  for  the  average  child, 
will  make  possible  the  early  recognition  of 
such  conditions  as  those  mentioned  and  the 
taking  of  proper  steps  for  their  correction. 

Children  who  are  much  below  weight  for 
height  usually  exhibit  other  symptoms. 
Nervously  two  ty^os  are  met  with :  One,  the 
dull,  listless  t}T)o,  not  infrequently  considered 
subnormal  mentally,  lacking  in  energy  and 
ambition,  easily  fatigued,  disinchned  to  exer- 
tion,   vdih    poorly    developed    muscles    and 


AMOUNT  OP   MALNUTRITION  2ID 

flabby  tissues ;  the  other  type,  ambitious,  often 
excitable,  usually  hard  to  manage,  energetic, 
in  fact  overactive,  never  still,  sleepless,  fre- 
quently with  good  muscular  development  but 
almost  no  subcutaneous  fat. 

If  we  take  the  best  figures  now  available, 
at  least  20  per  cent  of  our  American  Mlffiim' 
school  children  show  evidence  of  malnutri- 
tion by  the  standard  previously  laid  down; 
if  we  add  to  this  number  the  proportion  of 
those  of  pre-school  age  (not  infants)  and  of 
those  who  leave  school  and  go  to  work  before 
they  are  fully  grown,  we  obtain  a  total  of 
something  between  eight  and  ten  millions  of 
children  in  the  United  States  who  are  not  get- 
ting the  square  deal.  In  by  far  the  largest 
number,  fully  four-fifths  probably,  this  is  a 
remediable  condition  and  there  is  no  reason 
for  its  continuance  except  ignorance  and  in- 
difference. 

The  treatment  of  this  situation  must  in- 
clude both  preventive  and  remedial  measures, 
and  of  the  two  the  former  is  vastly  more  im- 
portant. If  preventive  measures  could  be 
generally  applied  a  great  improvement  would 
result,  not  only  in  the  health  of  the  children 
but  in  that  of  the  adults  of  the  country. 

Prevention  must  begin  with  the  application  PreTentivo 

"  ^  '^^  Maasures 

of  the  principles  of  eugenics,  with  suitable 


216  FOOD,    HEALTH  AND  GROWTH 

prenatal  care,  with  maternal  nursing  and  the 
best  infant  feeding  and  hygiene.  These  we 
will  pass  over,  not  because  we  think  them  un- 
important or  unrelated  to  health  conditions 
at  a  later  period,  for  the  state  of  nutrition 
at  each  period  of  life  has  a  very  close  rela- 
tion to  the  succeeding  one,  but  the  period  of 
infancy  has  been  widely  studied  and  is,  com- 
paratively at  least,  well  understood.  It  is 
with  the  older  child  that  we  are  now  specially 
concerned. 

It  is  during  the  period  immediately  after 
infancy  that  the  child  perhaps  has  been  most 
neglected.  His  hours  of  feeding,  the  charac- 
ter of  his  food  and  its  preparation  are  in  too 
many  cases  identical  with  those  of  the  rest 
of  the  family.  He  is  still  a  very  susceptible 
individual  growing  rapidly  and  easily  dis- 
turbed by  adverse  conditions. 

How  is  he  to  be  reached?  Thus  far  there 
have  been  no  special  methods  proposed  for 
reaching  this  class.  At  present  nothing  bet- 
ter offers  than  the  use  of  the  same  methods 
and  essentially  the  same  agencies  as  those 
which  have  been  shown  to  be  successful  in 
the  case  of  infants.  What  has  been  done  for 
the  infants  has  been  accomplished  chiefly  by 
the  education  of  the  mother  through  home 
visits  of  the  nurse  and  attendance  at  the  milk 


EDUCATION  OF   MOTHERS  217 

station  or  clinic.  There  is  no  reason  why  the 
same  agencies  might  not  accomplish  quite 
as  much  in  teaching  the  mother  the  physical 
needs  of  her  children  from  infancy  to  school 
age. 

At  the  milk  stations  and  clinics  for  infants, 
weekly  attendance  is  aimed  at  and  bi-weekly 
attendance  is  essential  to  secure  proper  su- 
pervision of  a  baby.  The  greatest  motive  for 
return  visits  is  the  interest  awakened  in  the 
mother  in  the  baby's  weight.  This  is  some- 
thing tangible,  something  she  can  understand 
and  appreciate.  If  her  baby  is  gaining  regu- 
larly, she  is  happy  and  satisfied.  If  not  gain- 
ing or  if  losing,  she  is  disturbed,  usually 
enough  to  make  her  ready  to  change  hours, 
food  or  habits  to  secure  improvement. 

Continuous  observation  upon  the  weight, 
and  opportunity  for  frequent  advice  vdih  re- 
gard to  minor  symptoms,  which  are  insured  constant 
by  weekly  or  bi-weekly  attendance,  make  it  Neceasary 
possible  to  prevent  to  a  very  great  degree 
serious  disturbances  of  digestion  and  nutri- 
tion during  the  first  two  years. 

In  early  childhood  visits  need  not  be  made 
so  frequently ;  monthly  or  bi-monthly  attend- 
ance may  be  quite  sufficient.  But  the  en- 
deavour should  be  made  to  keep  up  the  same 
interest   in   growth   and   weight.     At   least 


218 


FOOD,   HEALTH  AND   GROWTH 


twice  a  year  every  child  should  have  a  gen- 
eral examination  by  a  physician. 

Records  are  of  course  indispensable  and 
may  be  continued  on  cards  similar  to  those 
used  for  the  first  year.  In  an  ideal  system 
each  child  on  entering  school  should  be  able 
to  present  to  the  teacher  and  school  phy- 
sician a  complete  record  of  the  essential 
facts  of  his  life  history  so  far  as  physical  con- 
ditions are  concerned.  Prom  this  time  on  his 
health  record  should  be  a  part  of  his  school 
record.  Consider  for  a  moment  what  an  ad- 
vantage it  would  be  if  such  a  record  were 
available  for  every  child. 

The  medical  examination  on  school  en- 
trance, especially,  should  be  a  thorough  one. 
It  should  certainly  include  as  a  minimum 
the  weight,  height  and  chest  measurement, 
tests  of  hearing  and  vision,  examination  of 
teeth,  tonsils  and  adenoids,  the  heart,  lungs, 
glands,  Feet  and  spine.  For  this  the  child 
should  be  stripped  and  the  examination  made 
in  the  presence  of  the  parent.  His  school 
hours,  work,  exercise,  athletics,  etc.,  could  all 
be  adjusted  on  the  basis  of  kno^^^l  facts. 
There  would  be  no  unpleasant  surprises  in 
the  discovery  of  uncorrected  defects,  for  all 
these  would  have  been  known  and  most  of 
them  remedied  before  school  life  was  begun. 


REDUCTION  OP  INFANT  MORTALITY     219 

It  would  be  most  desirable  to  have  such  an 
examination  repeated  at  the  beginning  of  each 
school  year.  With  funds  now  available  or 
likely  to  be  available  for  several  years  I  fear 
this  will  be  impossible.  A  thorough  semi- 
annual examination  should  however  be  made 
of  every  child  whose  school  work  falls  much 
below  the  average  and  this  should  include 
mental  tests. 

It  has  been  argued  by  some  that  the  vigour-  ta'ftSt 
ous  campaign  to  reduce  infant  mortality  has  no?  a  sIy- 
merelv  had  the  effect  of  bringing  about  the  urnit  but 

of  the  Un- 

survival  of  the  unfit,  and  that  these  children  fortunau 
are  carried  through  the  first  year  only  to  suc- 
cumb to  other  adverse  conditions  in  later 
childhood.  The  facts  do  not  bear  out  this  con- 
tention. Vital  statistics  show  that  with  a  re- 
duction in  infant  mortality  there  has  come 
about  an  even  greater  reduction  in  the  mor- 
tality for  the  periods  one  to  two  years  and 
two  to  five  years.  In  New  York  City  two 
three-year  periods  show  the  following  com- 
parison : 

7890-/892  1917-1919 

Deaths  under  1  year  were  26  per  cent  of  all  deaths — 14.4  per  cent  of  all 

"         1-2  years  "       8      "       —   4.0     "      "      "    " 

"        2-5  years         "       7     "       "    "     "       "     —  3.6    "      "      *'    " 

The  fall  in  the  mortality  rate  has  been  a 
gradual  and  steady  one  for  each  of  these  age 
periods  during  the  entire  twenty-seven  years. 


220  FOOD,    HEALTH   AND   GROWTH 

There  can  be  no  escape  from  the  conclusion 
that  improved  health  in  one  period  invariably 
improves  the  health  of  the  period  which  suc- 
ceeds it.  Healthier  infants  mean  healthier 
boys  and  girls,  and  healthier  boys  and  girls 
mean  a  stronger,  more  vigourous  and  health- 
ier generation  of  men  and  women. 

We  have  already  alluded  to  the  fact  that 
what  has  been  accomplished  in  the  improve- 
ment of  the  health  of  the  infant  and  the 
young  child  has  been  the  result  very  largely 
of  the  education  of  the  parents,  particularly 
the  mother.  This  education  forms  a  distinct 
and  very  important  part  of  the  field  of  pubhc 
health. 

It  is  coming  to  be  realised  that  the  most 
effective  way  to  prevent  disease  is  to  promote 
health.  In  the  campaign  against  tuberculosis, 
for  example,  all  have  come  to  recognise  that 
cleanliness,  abatement  of  the  spitting  nui- 
sance, proper  food,  exercise,  and  most  of  all 
fresh  air,  have  accomplished  far  more  than 
isolation  and  medicinal  treatment  of  those 
suffering  from  the  disease.  In  the  world-A\"ide 
campaign  against  hookworm  which  is  being 
carried  on  by  the  International  Health  Board 
it  has  been  found  that  while  the  infected  indi- 
viduals in  the  population  can  be  readily  cured, 


HEALTH   EDUCATION  221 

little  can  be  accomplished  in  stamping  out  the 
disease  except  through  education. 

It  makes  no  difference  then  what  the  par- 
ticular phase  of  the  health  problem  is  that  wo  personal 
are  seeking  to  solve,  whether  it  is  cardiac  Essential 
disease,  hookworm,  tuberculosis  or  simply 
malnutrition,  it  all  comes  back  to  the  educa- 
tion of  the  individual  in  matters  of  personal 
hygiene.  To  promote  health  is  not  quite  the 
same  as  to  prevent  disease  although  it  invari- 
ably has  that  effect.  It  is  upon  the  promotion 
of  health  that  the  emphasis  in  public  health 
work  is  now  very  properly  coming  to  be 
placed. 

With  reference  to  their  children  parents 
must  not  only  be  taught  the  extreme  suscepti- 
bility of  the  very  young  to  all  kinds  of  infec- 
tion, and  the  importance  of  keeping  all  sick 
persons  from  coming  in  contact  with  them, 
but  emphasis  should  be  placed  upon  the 
means  by  which  children  may  be  kept  well. 
Again,  that  the  function  of  the  young  child 
is  to  grow  and  that  this  occurs  when  proper 
food,  fresh  air  and  sleep  are  furnished.  A 
small  child  is  a  very  delicately  constructed 
bit  of  machinery,  easily  injured  and  even  x^ut 
completely  out  of  order  by  improper  hand- 
ling.    The  economic  side  must  also  be  im- 


222 


FOOD,   HEALTH  AND  GROWTH 


pressed,  that  though  meat  is  cheaper  than 
medicine,  milk  is  much  cheaper  than  meat, 
and  that  illness  is  much  more  expensive  than 
health. 

Again,  our  foreign  population  does  not  ap- 
preciate the  fact  that  in  a  climate  like  that  of 
our  Eastern  States,  children  need  a  different 
diet  from  that  required  for  example  in  South- 
ern Europe,  and  that  the  modern  Ameri- 
can way  of  feeding  children  is  really  an  im- 
provement upon  the  methods  which  they  have 
followed  in  their  former  homes,  even  though 
they  have  the  authority  of  centuries  of  usage. 
But  even  our  native-bom  American  is  quite 
as  impervious  to  modern  health  teaching. 
Dr.  Biggs,  the  pioneer  in  health  education  in 
this  country,  has  often  said  that  he  could 
teach  the  foreign  population  of  New  York  to 
adopt  a  health  measure  more  readily  than  the 
native  American,  and  often  much  more  read- 
ily than  the  medical  profession.  The  for- 
eigner has  a  respect  for  authority — or  at 
least  he  once  had — which  a  citizen  of  free' 
America  docs  not  possess. 

In  times  of  jrreat  emergency,  as  when  an 
epidemic  of  cholera  or  plague  threatens,  peo- 
ple will  do  almost  anything  they  are  told. 
They  will  avoid  stimulants,  boil  their  milk 
and  drinking  water,  practise  personal  cleanli- 


HEALTH  EDUCATION  223 

ness  and  even  clean  up  their  dirty  homes. 
But  the  influence  of  this  is  very  transient; 
when  the  scare  is  over  they  quickly  lapse  into 
their  former  habits. 

When  a  child  is  dangerously  ill  there  is 
nothing  the  average  parent  will  not  sacrifice 
to  save  him.  But  to  save  him  day  by  day  by 
giving  him  proper  food  and  training  him  to 
form  proper  health  habits,  is  something  the 
importance  of  which  most  parents  do  not 
yet  see. 

We  have  not  been  very  intelligent  with  re- 
spect to  our  health  teaching  in  the  past.  For 
the  most  part  we  have  been  endeavouring  to 
teach  adults  to  reform,  to  change  their  habits  ^"^n*' 
of  eating,  drinking,  bathing,  sleep  and  exer-  ^^^^ 
cise.  But  adults  do  not  like  to  reform.  It  has 
been  difficult,  almost  impossible  to  influence 
them  to  change  the  habits  which  they  have 
practised  all  their  lives.  Their  prejudices 
are  hard  to  remove. 

It  may  well  be  said  of  most  of  the  health 
knowledge  of  adults,  not  that  they  are  so 
ignorant  but  in  the  words  of  Artemus  Ward, 
''they  know  so  many  tilings  that  ain't  so.'* 
It  is  pretty  clear  that  we  have  wasted  most 
of  our  energies  because  we  have  begun 
wrong.  As  it  is  nmch  easier  to  form  than 
to  reform,  it  becomes  perfectly  evident  that 


224  FOOD,  HEALTH  AND  GROWTH 

if  we  are  really  going  to  change  the  health 
habits  of  people  we  must  teach  the  chil- 
dren. Workers  in  the  health  field  are  be- 
ginning to  appreciate  the  fact  that  the  health 
education  of  children  is  the  great  opportunity 
of  the  future,  as  yet  scarcely  touched.  It  is 
chudhood      becoHiing  more  and  more  clear  that  we  have 

iB  the  Time  ° 

begun  too  late  with  our  health  education. 
Childhood  is  the  time  before  habits  have  been 
formed  and  prejudices  established.  The  twig 
is  so  easily  bent  in  the  right  direction. 

The  health  education  of  the  child  should  be 
begun  at  an  early  age  and  in  the  home.  As  a 
matter  of  fact  this  is  what  is  always  the  case, 
although  the  kind  of  education  given  may  be 
of  a  most  undesirable  sort.  But  it  will  be  im- 
proved when  mothers  are  better  taught  and 
when  they  can  be  made  to  realise  its  value. 
However,  even  under  what  may  be  called  fa- 
vourable conditions,  the  health  teaching  of 
the  home  leaves  very  much  to  be  desired.  In 
the  homes  of  the  wealthy,  intelligent  nurses 
and  educated  governesses  sometimes  give 
very  good  health  instruction  and  training; 
but  too  frequently  this  is  entirely  neutralised 
by  the  example  of  parents  and  their  indulg- 
ence of  the  children.  The  mother  who  takes 
entire  care  of  her  children,  even  though  in- 
telligent in  other  matters,  has  usually,  with 


HEALTH    EDUCATION  225 

her  other  domestic  duties,  very  little  time, 
has  seldom  the  knowledge  and  still  less  fre- 
quently realises  the  importance  of  the  early 
instruction  in  health  matters.  Comparatively 
few  children  in  our  modern  homes  have  been 
properly  trained  or  taught  in  matters  relat- 
ing to  their  health.  Some  other  instruction 
than  that  which  a  child  receives  in  his  home 
must  be  given,  or  each  generation  will  go  on 
for  an  indefinite  time  repeating  the  mistakes 
of  the  preceding  one. 

Clearly  the  school  is  the  place  where  it  can  5^,^^*^^^^^ 
be  done.  That  systematic  instruction  in  Homes"* 
health  should  form  part  of  the  school  curric- 
ulum and  that  education  in  matters  of  health 
is  quite  as  important  as  instruction  in  the 
''three  R's"  are  ideas  which  are  only  begin- 
ning to  da^vn  upon  the  minds  of  educators. 

The  school  in  many  particulars  offers 
advantages  over  the  home  as  a  place  for 
health  instruction.  The  child  goes  to  school 
expecting  to  be  taught.  What  his  teachers 
tell  him  or  what  he  learns  from  a  printed  page 
has  in  his  eyes  an  authority  which  home  teach- 
ing does  not  possess.  Besides,  during  the 
school  age  the  child  has  already  in  most  in- 
stances begun  to  rebel  against  the  prohibi- 
tions of  the  home  in  which  most  of  the  health 
teaching  of  the  home  consists.    In  the  health 


226 


FOOD,    HEALTH   AND   GROWTH 


HMath 

li&de 

SepolalTe 


Failure  of 
Former 
Scliool 
Taacblng 


teaching  of  the  past  no  effort  has  been  made 
to  make  health  attractive ;  too  often  I  fear  we 
have  succeeded  only  in  making  it  repulsive. 
A  continued  repetition  of  ''don't's"  and 
**you  mustn'ts"  has  very  little  influence  with 
average  boys  or  girls,  whether  it  relates  to 
their  speech,  their  posture,  their  manners  or 
their  health. 

Another  advantage  of  the  school  is  the  op- 
portunity it  affords  for  the  stimulus  of  emula- 
tion and  for  group  instruction.  It  is  much 
easier  to  get  a  group  of  thirty  or  forty  chil- 
dren in  a  school  room  to  do  things  than  to  in- 
fluence a  single  child  to  do  them.  Children 
at  this  age  are  greatly  influenced  by  the  opin- 
ions and  the  conduct  of  their  fellows.  Once 
proper  health  ideas  and  traditions  can  become 
established  in  a  school,  a  public  opinion  is 
created  which  makes  possible  a  widely  varied 
kind  of  health  teaching.  In  the  six  or  eight 
years  of  school  life  the  child  may  be  made  to 
understand  the  simplest  rules  of  personal 
health  and  the  broader  aspects  of  public 
health. 

But,  some  one  says,  have  not  our  schools 
been  teaching  physiology  and  hygiene  for 
a  generation  or  more?  In  the  advanced 
grades  and  in  the  high-school,  yes;  but  howf 
These  subjects  have  almost  without  exception 


HEALTH  EDUCATION  227 

been  made  a  matter  of  text-book  instruction 
and  recitation.  Children  were  taught,  for  in- 
stance, the  number  of  bones  in  the  body,  the 
composition  of  the  gastric  juice ;  they  learned 
that  in  the  lungs  the  body  gives  off  CO2  and 
takes  up  oxygen;  but  that  those  things  had 
any  relation  to  the  kind  of  food  they  should 
eat  or  to  the  necessity  of  keeping  the  win- 
dows of  their  sleeping-rooms  open,  was  sel- 
dom even  suggested. 

The  teaching  of  these  subjects  influenced 
the  health  habits  of  the  pupils  no  more  than 
their  study  of  botany.  They  were  not  linked 
up  with  practical  life.  A  new  and  more  vital- 
ised method  of  teaching  must  be  devised  if  re- 
sults are  to  be  obtained. 

A  wide,  g(?neral  interest  has  been  awakened 
in  the  last  few  years  in  physical  education, 
and  this  is  regarded  by  many  school  authori-  wiuphysi- 
ties  as  the  solution  of  the  problem  of  health  in  tion  and ' 

Training 

the  schools.  Phvsical  training  has  been  made  Accomplish 
compulsory  m  some  of  our  states.  Liberal 
appropriations  have  been  made  by  both  state 
and  local  authorities  and  the  physical  di- 
rector is  in  many  places  o;ie  of  the  highest 
paid  school  instructors.  All  this  has  been  em- 
phasised very  largely  as  a  result  of  the  rev- 
elations of  the  draft  which  revealed  such  a 
deplorable  condition  of  i)hysical  development 


228 


FOOD,    HEALTH  AND  GROWTH 


Danger  of 
Too  Mndi 
Emphasis 
Being 
Placed  on 
Field  Day 


among  our  young  men,  nearly  one-third  of 
whom  were  found  physically  unfit  for  mili- 
tary service.  Whether  the  problem  of  the 
health,  nutrition  and  physical  development  of 
our  children  is  going  to  be  solved  along  the 
lines  of  physical  education  as  now  conducted 
seems  very  doubtful. 

The  fundamental  error  appears  to  me  to  be 
the  belief  that  all  or  at  least  most  of  the  evils 
and  failures  which  have  been  so  obvious  can 
be  overcome  or  prevented  by  exercise,  or  ex- 
ercises and  physical  training.  Attention  is 
too  often  concentrated  upon  the  gymnasium 
and  the  showing  made  on  field  day.  How  far 
this  is  from  solving  the  health  problem  the 
following  incident  related  to  me  by  a  health 
worker  in  another  state  will  indicate:  The 
girl  who  was  taking  a  leading  part  in  field 
day  was  in  such  a  poor  state  of  health  that 
she  was  obliged  to  omit  all  her  school  work 
for  many  days  and  so  exhausted  was  she 
after  going  through  her  part  that  she  was  ex- 
cused from  her  studies  and  was  allowed  to 
remain  the  rest  of  the  day  in  bed. 

The  ambition  of  school  heads  to  make  a 
good  showing  on  field  day,  especially  at  inter- 
scholastic  meets,  and  the  natural  desire  of  all 
children  to  take  part  in  such  events  and  to 
excel  in  them  is  all  very  well.    It  has  its  ad- 


HEALTH  EDUCATION  229 

vantages;  but  encouraging  these  things  is 
very  different  from  promoting  the  health  and 
best  physical  development  of  the  school  as  a 
whole. 

The  fundamental  mistake  made  is  that  exer- 
cise and  physical  training  are  too  often 
looked  upon  as  ends,  not  as  a  means  to  an 
end.  By  entirely  ignoring  the  question  of 
the  nutrition  of  the  pupils,  and  the  effect  upon 
it  of  physical  exercises  prescribed  and  actu- 
ally performed,  the  so-called  physical  educa- 
tion may  result  in  a  positive  harm  instead 
of  benefit  to  the  individual,  as  in  the  instance  Best 
above  cited.  Periods  of  rest,  not  hours  of  Nt:e°88lry" 
exercise  in  the  gymnasium,  are  what  very 
many  of  these  children  need  most. 

It  seems  quite  evident  that  the  problem  of 
the  nutrition  of  school  children  is  not  going 
to  be  solved  by  physical  education  as  now  con- 
ceived and  administered  in  the  great  ma- 
jority of  our  schools.  Instruction  in  physical 
education  is  not  health  teaching  in  the  sense 
that  we  have  in  mind.  In  some  states  the  pro- 
gram for  physical  education  includes  much 
more  than  I  have  suggested. 

Physical  education  should  coriaiiily  include 
the  formation  of  proper  hoaltli  habits.  In 
theory  this  view  is  held  by  most  teachers 
of  physical  education,  but  how  little  it   is 


230 


FOOD,   HEALTH  AND  GROWTH 


emphasised  in  practice  is  indicated  by  the 
syllabus  of  one  state  which  devotes  285 
pages  to  a  detailed  description  of  exercises 
and  but  a  single  paragraph  to  food  habits. 

Health  teaching  should  be  begun  in  the  first 
grade  at  school  entrance,  and  continued 
through  all  the  grades  of  the  elementary 
school.  The  idea  should  be  grasped  at  the 
outset  that  the  aim  of  this  teaching  is  to  get 
children  to  do  tilings.  We  must  not  seek,  at 
this  age,  to  impart  information  about  health, 
or  to  teach  them  to  recite  the  rules  of  health, 
but  to  form  what  we  cannot  better  describe 
than  good  health  habits. 

Lectures  and  health  talks  accomplish  very 
little  with  children  of  any  age  and  nothing  at 
all  with  young  children.  Such  talks  w^hen 
made  a  part  of  the  regular  school  curriculum 
are  likely  soon  to  degenerate  into  advice  as 
to  how  to  prevent  taking  cold,  admonitions  to 
wear  rubbers,  keep  out  of  draughts,  avoid 
children  who  are  coughing  and  sneezing,  etc. 
They  are  a  bore  both  to  teacher  and  pupil. 

To  determine  the  value  of  different  means 
of  teaching  health  to  children  the  following 
experiment  was  tried  upon  a  large  group: 
First,  the  children  were  given  a  talk  upon 
health,  impressing  its  value  and  importance. 


HEALTH  EDUCATION  231 

Later  they  were  taken  to  a  health  exhibit 
where  they  were  showm  with  full  explanations 
various  charts,  diagrams,  etc.  Another  day 
they  were  showTi  a  health  film  at  a  moving  pic- 
ture theatre.  After  an  interval  the  children 
were  required  to  write  compositions  upon 
w%at  they  had  learned  about  health.  Only 
one  or  two  mentioned  the  health  talk;  a  few 
the  health  exhibit,  while  nearly  all  described 
fully  what  they  had  seen  in  the  picture  film. 

Such  results  are  most  instructive.  They 
show  that  we  must  teach  health  as  we  teach 
other  things  successfully,  by  the  use  of  meth- 
ods which  appeal  to  the  child,  by  things  he 
can  understand. 

Since  our  aim  with  young  children  is  the 
formation  of  habits,  the  problem  becomes  one, 
first,  of  selecting  the  most  important,  and 
then  of  devising  means  to  secure  their  con- 
stant repetition  until  they  become  automatic. 

The  habits  stressed  by  the  Child  Health 
Organisation  are  as  follows : 

A  full  bath  more  than  once  a  week  Hwat^^ 

Brushing  the  teeth  at  least  onee  every  day        HabitB 
Sleeping  long  hours  with  windows  open 
Drinking  as  much  milk  as  possible,  but  no  cof- 
fee or  tea 
Eating  some  vegetables  or  fruit  every  day 


232  FOOD,   HEALTH  AND  GROWTH 

Drinking  at  least  four  glasses  of  water  a  day 
Playing  part  of  every  day  out  of  doors 
A  bowel  movement  every  morning 

These  are  very  simple  things,  but  if  regularly 
practised  by  all  children  they  would  certainly 
bring  about  a  very  marked  improvement  in 
their  physical  condition.  To  the  physician 
these  habits  are  known  as  the  laws  of  health ; 
to  the  children  they  are  taught  and  practised 
as  the  *' Rules  of  the  Game." 

How  to  get  thom  done  by  children,  not  for 
a  few  days  or  weeks,  but  regularly  and  con- 
tinually during  school  life — this  is  the  prob- 
lem. 

We  must  not  then  make  ivork  of  our  health 
teaching  in  the  school,  but  seek  to  make  it 
play;  we  can  got  children  to  do  almost  any- 
thing if  it  is  made  play.  We  should  aim  to  get 
into  their  minds  that  health  too  is  a  game, 
with  its  rules  like  other  games ;  a  game  that 
one  can  win  or  lose  according  as  he  obeys  the 
rules.  The  play  motive  is  altogether  the  most 
successful  one  up  to  the  age  of  ten  or  eleven. 
Unless  the  child  is  interested,  it  is  hopeless 
to  attempt  to  influence  him;  so  we  begin  if  we 
can  with  something  wliich  is  dramatic  and 
which  will  catch  the  child's  interest,  like  Cho- 
Cho  the  Health  Clo^^^l,  the  Jolly  Jester,  the 
Health  Fairy,  or  some  of  the  other  dramatic 


HEALTH  EDUCATION  233 

characters,  first  developed  by  the  Child 
Health  Organisation,  who  introduce  health 
teaching  under  the  guise  of  amusement  or  en- 
tertainment. Those  who  see  in  the  modem 
movement  for  the  health  education  only 
amusement  for  an  hour,  have  not  grasped  the 
point.  These  things  are  only  the  beginnings,  how  to 
the  first  lessons  in  health — kindergarten  les-  iiit«rMt 
sons  if  you  will;  but  they  are  based  upon 
sound  psychology — that  before  you  can  in- 
fluence, you  must  interest. 

If  one  is  skeptical  regarding  the  effect  of 
such  measures  let  him  watch  and  see  how 
much  real  interest  can  be  aroused,  how  chil- 
dren are  impressed  and  how  well  they  remem- 
ber w^hat  they  are  taught  in  this  way.  Health 
teaching  can  be  correlated  with  instruction  in 
reading,  writing  and  arithmetic  without  tak- 
ing extra  time  in  the  curriculum. 

"WTien  a  little  older,  children  love  organisa- 
tion; at  a  certain  age,  usually  about  twelve 
or  thirteen  years,  they  like  nothing  so  much  J^'iTiJ^^ 
as  to  belong  to  a  club,  to  wear  badges  or  a 
uniform.  Hence  the  response  which  has  come 
from  the  ^lodern  Health  Crusade  movement, 
and  the  success  which  has  attended  the  for- 
mation of  various  types  of  health  clubs  or 
health  leagues,  in  which  records  are  kept  of 
the   daily  performance   of   certain   "Health 


234 


FOOD,   HEALTH  AND   GROWTH 


Chores"  like  the  Rules  of  the  Game  men- 
tioned, and  where  inspections  are  made  daily 
by  the  oflBcers  to  see  how  well  the  chores 
have  been  done. 

All  these  movements  are  attempts  to  capi- 
talise certain  instincts  of  the  child,  and  when 
well  administered  they  can  be  made  of  very 
great  value.  The  only  difficulty  is  that  after 
a  time  children  almost  inevitably  lose  interest, 
and  the  continued  repetition  of  the  same  per- 
formances may  become  something  of  a  bore. 
Something  more  must  be  devised  to  maintain 
their  interest  if  the  health  habits  we  are  seek- 
ing to  have  children  form  are  to  become 
habitual  with  them. 

Right  here  is  the  opportunity  for  a  teacher 
Avith  tact  and  imagination  to  utilise  any  spe- 
cial interest  of  the  child  to  carry  the  health 
lesson.  The  following  incident  illustrates  this 
point : 

Miss  M.  had  been  appointed  a  special 
teacher  of  an  open-air  class  in  one  of  the  pub- 
lic schools  of  a  large  city.  She  became  very 
much  interested  in  the  health  of  her  boys  and 
girls,  but  she  thought:  ''How  can  I  teach 
them  health?  I  have  never  had  any  special 
training  in  the  subject."  One  day  she  had  an 
opportunity  to  talk  to  an  expert  on  health  edu- 
cation who  told  her  that  she  needed  no  tech- 


HEALTH  EDUCATION  235 

nical  knowledge  to  teach  the  simple  laws  of 
health;  that  any  teacher  could  interest  her 
pupils  in  learning  to  drink  milk,  eat  green 
vegetables  and  have  plenty  of  fresh  air  and 
sleep,  if  she  w^ent  about  it  in  the  right  way. 
She  was  told  of  various  devices  for  arousing 
the  children's  interest  but  she  was  not  satis- 
fied. Her  city  street  boys  were  not  of  the 
type  to  be  interested  in  fairies.  She  had 
become  enthusiastic,  however,  over  the  idea 
of  dramatising  health  education  and  at  last 
she  stumbled  on  the  magic  word;  it  was 
''Sport."  Her  boys  were  inveterate  readers 
of  the  sporting  page  and,  as  it  happened, 
horse  racing  was  the  particular  excitement  at 
this  time.  Miss  M.  also  took  to  reading  the 
sporting  page.  To  her  surprise  she  found  it 
to  be  very  stimulating  literature.  The  time 
came  for  Man  o'  War's  great  race.  Miss  M. 
saw  her  chance  and  took  it.  She  discussed 
with  the  boys  what  the  difference  was  between 
a  race  horse  and  an  ordinary  horse,  and  ex- 
plained the  wonderful  care  he  received ;  how  importance 
his  coat  was  washed  and  brushed  every  day,  euim**/^ 
his  mane  combed,  his  food  carefully  measured  Kact  Horse 
so  that  he  took  neither  too  little  nor  too  much 
and  how  it  was  given  at  regular  hours ;  how 
he  was  given  plenty  of  water  at  proper  times 
but  never  when  he  was  hot ;  how  he  was  exer- 


236  FOOD,    HEALTH   AND   GROWTH 

cised  regularly  every  day  out  of  doors  and 
had  a  nice  quiet  place  to  sleep,  etc.  The  in- 
ference was  ob\ious. 

The  boys  would  now  come  to  school  ahead 
of  time  every  day  to  discuss  Man  o '  War  with 
Miss  M. ;  on  the  day  of  the  race  they  came  a 
whole  hour  before  opening.  The  next  day 
they  were  asked  to  write  about  it.  Their  com- 
positions showed  that  the  point  had  been 
driven  home,  they  were  fairly  bursting  with 
the  inevitable  connection  between  cause  and 
effect.  Man  o'  War  had  to  win  because  he 
had  followed  the  "rules  of  the  game."  One 
little  boy  wrote:  "Gee,  if  you  could  have 
seen  Man  o'  War  coming  around  the  curve 
with  his  coat  a-shining  in  the  sun  you  would 
know  he  just  couldn't  help  \\dnning." 

It  was  not  hard  after  this  for  Miss  M.  to 
get  her  pupils  to  practise  the  health  rules. 

Special  training  and  equipment  are  useful 
but  not  essential.  The  one  thing  which  is 
indispensable  is  a  person  with  tact  and  en- 
thusiasm. Of  such  material  as  Miss  M.  will 
the  health  teachers  of  the  future  be  made. 

The  dramatic  instinct  of  children  can  be 
useaof         utilised   in   the   production   of   little   health 

Health  ^ 

pi»y»  plays,  like  those  of  Eleanor  Griffith.    With  en- 

couragement and  a  little  help  from  the  teach- 
ers, children  themselves  have  written  some 


HEALTH  EDUCATION  237 

very  creditable  plays.  Milk  is  most  often 
the  subject  and  the  different  constituents  of 
the  milk  are  the  different  characters.  The  vil- 
lain of  a  play  is  often  tea  or  coffee  while  milk 
is  the  heroine. 

The  exhibition  of  good  posters  in  the  school- 
room and  poster  contests  among  the  children 
may  be  a  means  of  teaching  health  as  well 
as  dramng.  The  contests  may  be  between  the 
boys  and  the  girls,  between  different  rooms 
in  a  large  school,  or  the  competition  may  be 
a  more  general  one  between  all  the  schools  of 
a  city  or  county.  Such  a  competition  with 
prizes  was  recently  held  in  New  York;  with 
a  little  newspaper  publicity  much  interest 
was  aroused  and  some  very  excellent  health 
posters  produced.  All  the  posters  were  ex- 
hibited for  several  days  in  one  of  the  rooms 
of  the  Metropolitan  Museum  of  Art  and  the 
prize  posters  displayed  in  a  prominent  shop- 
window. 

Health  rh^Tnes  of  the  sort  which  appeal  to 
children   arc   anothor  wav   of   Icachine:   the 


Health 

P08t«r8 


Health  Les- 
sons In 
Catchy 

ick  Peterson  aro  excolloiit  examples:  Bhymes 


same  lesson.    The  following  bv  Mrs.  Freder-  ca°ch^ 


There  was  an  old  Jiian  with  a  tooth 
That  ached  till  he  said,  it's  the  truth, 
I  neglected  Vmu  youn^.  and  now  1  am  stung. 
IIow  T  wish  I  had  hrushed   'em  in  youth ! 


238 


POOD,   HEALTH  AND   GROWTH 


There  was  a  boy  in  our  town  whose  mother  was  not 

wise. 
Coffee  and  tea  he  used  to  get  and  grew  up  under- 

size. 
But  when  he  failed  the  football  team  because  his 

size  was  small, 
He  cut  out  both  and  took  to  milk  and  grew  up  very 

tall. 


Interest  in 
Weight 
the  Most 
Lasting 


The  health  lessons  stressed  in  such  verses 
are  not  easily  forgotten  by  children.  Why 
should  they  not  be  taught  them  as  well  as 
Mother  Goose  rhjTnes?  When  accompanied 
by  appropriate  pictures  they  form  an  at- 
tractive decoration  for  the  room  of  the  kin- 
dergarten or  the  primary  class. 

The  remarkable  success  of  Mrs.  Peterson's 
Child  Health  Alphabet  (nearly  two  and  a 
quarter  million  copies  of  which  have  already 
been  distributed)  is  the  most  conspicuous  ex- 
ample of  the  need  of  such  literature  for  small 
children  and  its  value  as  a  means  of  teach- 
ing them. 

Of  all  the  methods  proposed  for  maintain- 
ing an  interest  in  health  matters  in  children 
of  all  ages,  none  has  been  so  generally  useful 
as  that  which  centers  about  the  weight  and 
height.  Tt  is  no  exaggeration  to  say  that  the 
scales  have  saved  the  lives  of  more  infants 
than  any  device  of  medical  or  surgical  treat- 
ment. 


HEALTH  EDUCATION  239 

And  right  here  may  I  digress  and  say  a 
word  with  reference  to  tables  giving  stand- 
ards of  height  and  weight  which  have  been  a 
subject  of  so  much  recent  discussion  as  to 
discredit  in  some  quarters  their  value?  The 
differences  between  nearly  all  the  tables  now 
in  use  are  more  apparent  than  real  and  are 
owing  chiefly  to  the  difference  in  the  manner 
of  presentation. 

By  many  who  have  discussed  this  subject 
the  main  point  has  apparently  been  missed. 
The  chief  purpose  of  weighing  children  in 
school  is  not  to  collect  anthropometric  statis- 
tics, but  to  interest  children  in  health.  The 
actual  relationship  between  weight  and  height 
of  a  child  at  the  beginning  of  observation  is 
of  much  less  importance  than  his  rate  of  prog- 
ress. It  is  ^vith  the  latter  that  health  teaching 
is  most  vitally  connected. 

It  is  of  course  necessary  that  scales  should 
be  in  the  schools,  and  that  weights  be  taken  OTOBec«d 
regularly  during  the  school  year,  usually  once 
a  month.  The  weights  for  the  children  of  a 
single  room  may  be  entered  upon  a  large  chart 
hung  in  a  conspicuous  place.  Opposite  the  in- 
itial weight  the  average  weight  for  the  height 
is  recorded  so  that  the  child  can  see  where 
he  stands  and  what  progress  he  is  making 
each  month. 


240  FOOD,   HEALTH  AND   GROWTH 

Various  other  devices  are  used  with  the 
younger  children.  In  one  primary  class- 
room I  saw  a  large  sheet  of  paper  upon 
which  was  drawn  the  ladder  of  health,  the  dif- 
ferent rungs  of  which  are  marked  from  the 
bottom  ''going  up,"  ''almost  there,"  "on  the 
level,"  "over  the  top,"  each  child  making  his 
own  entry  after  the  weighing.  The  device 
in  another  room  was  a  row  of  small  paste- 
board clocks,  one  made  by  each  child,  on 
which  was  shown  by  the  minute  hand  the  ex- 
isting weight,  and  by  the  hour  hand  the  nor- 
mal average  weight  for  the  child 's  height  and 
age.  The  minute  hand  is  moved  up  or  down 
as  he  gains  or  loses  at  the  monthly  weighing. 
These  are  kindergarten  methods,  truly,  but 
they  accomplish  the  result  aimed  at — they 
gain  and  hold  the  child's  interest  at  a  cer- 
tain age. 

One  must  see  one  of  these  monthly  weigh- 
ings properly  conducted  to  appreciate  their 
significance.  They  arc  made  important,  often 
solemn,  occasions,  and  the  interest  of  the 
children  is  often  intense.  The  scales  are 
placed  at  the  point  of  the  weight  taken  the 
previous  month  and  when  a  child  steps  upon 
the  platfoiTTi  eager  eyes  watch  whether  the 
bar  will  rise  or  fall,  indicating  a  gain  or  loss 
for  the  month.    When  the  weighing  is  finished 


HEALTH   EDUCATION  241 

one  teacher  addresses  he^-  children  somewhat 
as  follows:  **Now  will  every  child  in  the 
room  who  is  up  to  normal  weight  for  height 
stand  up."  ''Children,  I  could  tell  it  by  your 
looks;  by  your  bright  eyes  and  rosy  cheeks, 
by  the  work  you  did  in  school  this  month,  by 
the  way  you  play  at  recess,  etc.,  etc." 

All  of  course  are  delighted. 

**Now,  mil  every  child  who  gained  in 
weight  last  month  stand." 

More  words  of  commendation  follow,  then 
the  teacher  says  to  a  group — 

' '  Now  won 't  you  tell  us  how  you  did  it. ' ' 

Many  hands  go  up  as  each  Avishes  to  relate 
his  ovni  personal  experience.  It  is  not  neces- 
sary to  call  attention  to  those  who  did  not 
gain  or  who  are  below  normal  weight. 

A  common  cause  of  under-weight  is  that 
the  child  has  no  appetite  and  will  not  eat 
simple  nourishing  food.  The  mother  says, 
'*he  must  have  some  breakfast  before  school,  Bad  rood 
so  I  give  him  coffee  and  a  roll,  or  griddle 
cakes  with  syrup  which  he  will  eat,  rather 
than  have  him  go  to  school  with  no  breakfast 
at  all."  To  change  things  in  the  home  is 
diflBcult ;  in  some  homes  it  is  impossible,  but 
in  the  school  it  can  be  done.  The  child  with 
such  habits  finds  in  school  that  he  is  at  the 
foot  of  the  class  in  health.    To  e:ain  he  will 


Habits 


242 


POOD,   HEALTH   AND   GROWTH 


Creating  an 
Ambltipn  to 
be  Healtby 


CondltionB 
NecMsary 
toQaluiiLg 


now  go  to  bed  at  a  reasonable  hour,  eat  his 
cereal  and  drink  his  milk  and  soon  he  often 
finds  he  likes  them. 

When  a  child  is  found  at  the  monthly  weigh- 
ing to  be  much  under-weight  or  not  gaining 
he  is  anxious  to  know  why.  He  wants  to  be 
in  the  healthy  group.  Now  is  the  opportu- 
nity to  stress  the  health  rules.  Advice  to  a 
child  who  wants  to  know  is  never  wasted  ef- 
fort. He  is  ready  to  submit  to  a  medical 
examination,  have  teeth  extracted  or  tonsils 
and  adenoids  removed,  if  these  seem  to  be  the 
cause.  But  the  influence  of  this  does  not  stop 
at  the  school  door;  as  these  health  records 
go  home  to  the  mother  on  the  monthly  report 
card,  her  interest  is  awakened  and  with  little 
difficulty  her  cooperation  is  secured;  in  fact, 
the  child's  zeal  makes  this  almost  inevitable. 

The  home  is  reached  through  the  child  and 
many  a  mother  may  now  learn  for  the  first 
time  what  is  a  suitable  diet  for  a  school  child 
and  what  habits  are  indispensable  for  health 
and  growth. 

When  a  child  has  learned  that  to  get  up  to 
his  normal  weight  or  to  gain  weight,  he  must 
be  in  bed  before  nine  o'clock  and  not  play  in 
the  street  till  ten  or  eleven;  that  he  must 
drink  milk,  not  tea  and  coffee;  eat  regular 
meals,  not  fill  his  stomach  with  sweets  and 


HEAX.TH   EDUCATION  243 

other  trash  between  meals,  must  eat  a  va- 
riety of  food — cereals,  vegetables,  fruit,  etc., 
and  not  make  his  entire  meal  of  one  thing  no 
matter  how  fond  he  may  be  of  it — does  any 
one  suppose  that  such  habits  formed  in  child- 
hood will  not  make  a  lasting  impression  upon 
his  lifet 

Too  much  emphasis  cannot  be  placed  upon 
the  fact  that  the  essentials  of  personal  health 
are  such  simple  things  as  those  mentioned, 
and  that  even  the  untrained  teacher,  once  she 
is  interested,  can  carry  them  into  effect. 
Emulation  and  competition  are  powerful  mo- 
tives in  childhood,  and  while  they  are  often 
unduly  stimulated,  they  are  very  valuable  in-  f^fronj"^ 
centives  to  children  to  do  much  that  is  desir-  **"**^» 
able. 

In  a  school  atmosphere  like  the  one  de- 
scribed— and  this  is  not  a  fancy  sketch,  many 
such  exist — such  a  public  opinion  as  to  the  de- 
sirability of  health  exists  that  nothing  can  re- 
sist it.  Children  are  taught  health  songs,  to 
produce  health  plays,  to  make  health  posters, 
to  devise  health  games  and  health  charts.  One 
must  see  it  to  appreciate  the  interest  the  lit- 
tle children  take  in  these  things,  and  the  fun 
they  get  out  of  it ;  the  pride  they  take  in  being 
up  to  weight  and  their  delight  at  the  regular 
monthly  gain.    One  is  touched  too  by  the  con- 


244  POOD,    HEALTH  AND  GROWTH 

scientious  efforts  of  those  who  are  below  to 
gain  and  to  bring  their  weight  up  to  normal. 
One  little  fellow  of  seven  years  I  saw  who 
was  nine  pounds  below  weight  and  who  had 
formerly  had  coffee  three  times  a  day  but  who 
was  bravely  drinking  his  milk  and  eating  his 
oatmeal  to  be  in  the  healthy  group,  and 
getting  to  like  them  too.  Children  are  taught 
to  think  health,  to  live  health,  not  to  recite  it. 
Much  of  this  is  looked  upon  at  first  \vith 
doubt  by  parents,  askance  by  school  boards, 
and  with  suspicion  by  physicians;  but  once 
they  wdtness  the  results  achieved  in  improved 
physical  condition  and  better  school  work 
they  are  compelled  to  admit  its  effectiveness 
and  its  value. 

Children  do  not  by  these  methods  become 
Ideas  not  sclf-couscious  regarding  their  health;  noth- 
ing is  suggested  as  to  disease,  bacteria,  the 
dangers  of  infection,  etc.  Health  as  a  thing 
to  be  gained,  to  be  kept  and  to  be  enjoyed; 
health  as  contributing  to  success  in  athletic 
games — these  are  things  which  are  kept  be- 
fore their  minds. 
TMching  Older  children  can  understand  also  many 

chiiii^  of  the  more  important  problems  in  public 
health.  For  instance,  the  enonnous  loss  of 
life  and  property  in  epidemics;  the  connec- 
tion between  them  and  faulty  hygiene  and 


HEALTH   EDUCATION  245 

sanitation ;  the  fact  that  they  may  be  spread 
by  unhealthy  persons  who  handle  food,  or 
through  a  contaminated  milk  or  water  sup- 
ply, or  by  mosquitoes,  flies,  rats,  lice  and 
other  vermin,  and  that  many  of  these  diseases 
can  be  communicated  from  one  person  to 
another,  and  why  quarantine  is  necessaiy  in 
such  diseases.  They  can  also  be  taught  to 
appreciate  the  value  of  clean  streets,  the 
necessity  of  proper  disposal  of  sewage  and 
garbage.  How  diphtheria,  smallpox  and  yel- 
low fever  have  been  conquered,  and  the  re- 
sults of  the  campaign  against  tuberculosis 
and  typhoid  fever,  should  be  known  to  every 
one,  and  there  is  no  reason  why  this  might 
not  be  given  in  schools.  Some  of  our  best 
modem  books  on  hygiene  like  Winslow's 
"Healthy  Living"  give  this  information  in 
readable  form. 

These  health  stories  must  be  graphically 
told  by  one  who  has  the  gift  of  writing  for 
children  and  most  of  all  they  must  be  accu- 
rate as  to  fact  and  told  without  exaggeration. 
They  must  be  better  than  literature  which 
was  put  into  our  schools  regarding  the  in- 
jurious effects  of  alcohol.  I  am  reminded 
in  this  connection  of  the  remark  of  a  boy 
who  was  gazing  out  of  a  sleeping  car  win- 
dow   at    a   vivid    sky    at    sunrise.      **Why, 


246 


FOOD,    HEALTH  AND   GROWTH 


Htftltb 
Tmnght  In- 
cide^Ully 
to  Other 
Subjvcta 


Mother"  he  exclaimed,  "it's  just  like  the  pic- 
ture of  the  inside  of  the  drunkard's  stomach 
in  my  school  reader." 

To  older  children  health  instruction  is  best 
given  not  as  a  subject  by  itself  but  incident- 
ally, correlating  it  with  other  subjects  of  the 
school  curriculum.  For  instance,  vnih  history 
and  economics,  study  the  failure  of  the 
French  to  build  a  Panama  Canal  and  the  suc- 
cess of  the  United  States  when  Gorgas  had 
shown  how  malarial  fever  could  be  stamped 
out ;  or  the  cleaning  up  of  Cuba  by  Leonard 
Wood  and  the  consequent  control  of  yellow 
fever,  which  previously  had  been  brought 
from  Cuba  to  the  ports  of  New  Orleans, 
Mobile  and  Savannah  every  few  years,  caus- 
ing epidemics  with  thousands  of  deaths  and 
costing  millions  of  dollars  by  paralysing  busi- 
ness in  these  cities  which  were  sometimes 
quarantined  for  months. 

In  mathematics  let  the  children  solve  prob- 
lems like  this :  Calculate  the  cost  of  erecting 
and  maintaining  a  water  filtration  plant  for 
a  city,  and  compare  this  with  an  annual  oc- 
currence of  one  hundred  cases  of  typhoid 
fever  each  year,  with  an  average  disability 
of  eight  weeks  for  each  case,  without  taking 
account  of  loss  of  life. 

In  debate  let  them  discuss  such  a  question 


HEALTH   EDUCATION  247 

as  the  following:  ** Resolved  that  our  city 
or  town  should  furnish  half  a  pint  of  milk 
a  day  at  morning  recess  to  every  child 
in  the  public  schools."  Think  what  an  op- 
portunity to  teach  those  who  take  part  in 
such  a  debate  the  uses  and  value  of  milk! 
And  what  a  chance  to  educate  the  school 
superintendent  if  he  could  be  induced  to  act 
as  one  of  the  judges  in  such  a  debate ! 

In  drawing  have  the  children  make  posters 
illustrating  some  health  rule,  such  as  an  early 
bed  hour,  sleeping  with  wdndows  open,  drink- 
ing milk,  not  tea  or  coffee,  etc. 

In  English  composition  tell  the  story  of  any 
great  health  achievement  like  Jenner's  dis- 
covery and  then  let  the  children  write  an  ac- 
count of  it. 

In  biography  why  should  not  children  in 
school  learn  as  much  of  the  life  and  work  of 
John  Harvey  as  of  Galileo ;  of  Louis  Pasteur 
as  of  Napoleon ;  of  Lister  as  of  Gladstone ;  of 
Robert  Koch  as  of  Bismarck;  of  Walter 
Reed  as  of  Andrew  Carnegie?  Appraised 
in  terms  of  their  value  to  the  human  race, 
is  not  the  influence  of  the  first  group 
mentioned  quite  as  important  as  the  sec- 
ond? 

These  are  only  a  few  suggestions  of  how 
the  teaching  of  health  might  be  made  real 


248 


POOD,   HEALTH  AND   GROWTH 


The  General 
Pnblic  Hu 
no  Back- 
ground of 
Health 
Education 


to  older  children  in  the  schools  without  taking 
any  time  from  other  studies.  Why  is  it  that 
it  is  so  difficult  to  get  popular  support  for 
advanced  public  health  measures!  I  believe 
it  is  chiefly  because  the  great  majority  of  our 
people  today  have  no  background  of  knowl- 
edge regarding  these  important  matters.  The 
boys  and  girls  in  our  schools  today  will  very 
soon  form  our  voting  population.  If  health 
teaching  is  made  a  regular  part  of  school  in- 
struction it  will  not  be  so  hard  to  secure 
necessary  health  legislation,  or  to  get  appro- 
priations voted  for  adequate  health  protec- 
tion of  the  community. 

Very  little  in  the  way  of  apparatus  or 
equipment  is  needed  for  such  health  teaching 
as  we  have  suggested.  The  one  thing  which 
is  essential  to  success  is  a  teacher  with  some 
enthusiasm  for  health;  without  this  the 
monthly  weighing  becomes  a  perfunctory 
performance  of  no  interest  to  the  pupils  and 
but  one  more  piece  of  drudgery  put  on  the 
shoulders  of  the  already  overworked  and 
often  undernourished  teacher.  Its  results  are 
merely  statistics  which  are  required  by  the 
principal  or  school  superintendent. 

One  of  the  by-products  of  the  plan  we  have 
described  has  often  been  the  discovery  by  the 
teacher  herself  that  she  is  far  below  weight, 


HEALTH   EDUCATION  249 

and  that  the  tea  and  coffee  with  which  she 
seeks  to  stimulate  her  jaded  nerves,  the  sweets  ^^^  ^^ 
she  consumes  because  she  has  no  appetite  for  S*^*'^'*' 
plain  food,  and  the  evenings  which  she  spends  ^••*^" 
in  seeking  diversion  from  the  deadly  routine 
of  school  work,  may  have  something  to  do 
with  it.    The  substitution  of  a  quart  of  milk 
a  day  for  her  tea  and  coffee,  eating  simple 
food  at  regular  hours  and  taking  one  or  two 
hours  more  of  sleep  a  night,  are  often  fol- 
lowed in  a  few  weeks  by  a  gain  of  six  or 
eight  pounds  in  weight;  and  mth  this  there 
frequently   comes   an   entirely   new   outlook 
upon  life  and  a  different  attitude  toward  her 
work. 

Who  is  to  teach  the  teacher?  Where  is 
she  to  get  the  inspiration  and  the  knowledge 
which  will  enable  her  to  take  the  initiative  in 
maintaining  and  improving  the  health  of  her 
pupils?  Our  greatest  need  today  in  this  edu- 
cational health  program  is  trained  people  to 
teach  the  teachers ;  not  simply  to  give  them 
the  facts  of  health,  but  the  enthusiasm,  which 
is  needed  to  make  these  things  vital  in  the  instmcuon 
life  of  the  child.  This  ought  to  be  given  in  L  Hwath" 
teachers'  institutes,  in  our  colleges  and  high- 
schools  from  which  our  teachers  are  recruited, 
and  most  of  all  there  should  be  in  our  nor- 
mal schools  up-to-date  courses  upon  health 


250  FOOD,   HEALTH  AND  GROWTH 

education  which  every  teacher  should  be  re- 
quired to  take. 

It  is  impossible  here  to  describe  in  detail 
how,  once  the  spirit  of  health  teaching  exists 
in  a  school,  this  teaching  can  be  correlated 
r^ZS^t^  with  other  school  w^ork.  It  should  be  closely 
oweiatwi  linked  up  with  the  Domestic  Science  Depart- 
ment and  the  work  of  the  physical  director. 
All  this  can  be  done  without  imposing  extra 
burdens  upon  the  teacher  or  the  school  curri- 
culum. For  suggestions  along  these  lines  I 
would  refer  to  two  pamphlets  prepared  by 
the  Child  Health  Organisation  and  issued  by 
the  Department  of  Education  in  Washing- 
ton ;  one  by  Robert  G.  Leavitt  of  the  Trenton 
Normal  School  on  ''The  Health  of  the 
Teacher"  and  the  other  by  J.  Mace  Andress 
and  Mabel  Bragg  entitled  "Suggestions  for 
Teaching  Health  in  the  Elementary'  Schools." 
These  are  full  of  practical  hints  and  should 
be  in  the  hands  of  every  teacher. 

While  the  teacher  alone  with  only  the  help 
we  have  mentioned  can  do  a  great  deal,  she 
cannot  do  it  all.  She  should  have  the  coopera- 
tion of  a  school  nurse  and  a  school  physician, 
and  in  cverj^  large  town  she  might  have  them, 
if  parents  appreciated  their  value. 

In  an  ideal  plan,  medical  school  inspection 
should  form  an  important  part  of  such  a  pro- 


HEALTH   EDUCATION  251 

gram  as  we  have  outlined,  and  should  be 
closely  linked  up  w^th  other  health  teaching. 
So  also  should  the  hot  school  lunch,  which  ^"J^ 
should  be  Rooked  upon  not  merely  as  a  means 
of  improving  the  nutrition  of  the  children, 
important  though  this  may  be,  but  as  hav- 
ing great  educational  value.  It  offers  a 
unique  opportunity  to  teach  children  all 
through  their  school  life  food  values,  food 
costs,  what  foods  are  necessary  for  growth 
and  what  are  undesirable.  It  has  proven  of 
the  greatest  value  in  teaching  children  to 
eat  proper  foods  and  to  connect  the  child's 
interest  in  his  weight  \vith  the  selection  of 
nutritious  food. 

The  school  nurse  is  needed  to  take  up  de- 
tails with  children  who  are  especially  in  need 
of  help.  She  can  go  into  the  home  and  secure 
the  cooperation  of  the  mother.  The  school 
physician  is  needed  to  discover  existing  dis- 
ease and  to  see  that  physical  defects  are  re- 
moved, which  may  be  the  cause  of  the  failure 
to  make  progress.  Then,  too,  time  must  be 
found  in  the  school  curriculum  for  the  regu- 
lar weighing  and  the  accompanying  health 
teaching.  They  should  not  be  done  out  of 
school  hours  as  if  they  were  no  real  part  of 
the  school  program. 

That  education  in  health  should  form  an 


252 


FOOD,   HEALTH  AND  GROWTH 


HealUi 
Inatrnctlon 
an  EssentUl 
Part  of  Pub- 
lic School 
EdncatiOQ 


integral  part  of  our  public  school  education, 
it  seems  to  me  is  a  position  which  is  unassail- 
able. Next  to  moral  training,  more  impor- 
tant in  its  relation  to  life  than  anything  else, 
is  health.  The  basis  of  adult  health  is  proper 
nutrition  during  g^o^vth.  To  insure  this  is 
one  of  the  great  problems  before  the  world 
today.  It  can  come  only  through  an  aroused 
and  enlightened  public  opinion.  But  the 
school  is  the  place  where  the  foundations  for 
it  must  be  laid. 

If  the  general  plan  of  preventive  measures 
just  outlined  is  followed,  the  need  for  reme- 
dial measures  will  be  greatly  reduced.  But 
it  may  be  a  considerable  period  before  these 
preventive  measures  are  adopted  even  in  en- 
lightened and  progressive  communities. 
Time  will  be  required  to  educate  public  opin- 
ion up  to  the  point  of  demanding  them.  Yet 
no  matter  what  preventive  measures  have 
been  adopted,  there  -vsill  always  be  a  certain 
number  of  children  whose  nutrition  is  below 
what  it  should  be.  At  the  present  time  this 
group  is  quite  a  large  one.  Among  the  well- 
to-do  a  child  with  malnutrition  should  be  un- 
der the  care  of  a  private  physician,  but  he 
seldom  is  except  where  the  parents  are  un- 
usually intelHgent  in  health  matters.  Among 
those  of  moderate  means  and  among  the  poor 


NUTRITION   CLASSES  253 

such  a  child  seldom  sees  a  physician  unless 
really  ill.     In  some  communities  organised 
effort  has  been  made  to  solve  the  problem  o 
malnutrition,  or  at  least  to  help  in  solving  it,' 
by  the  formation  of  Nutrition  Classes. 

It  is  possible  here  only  to  outline  the  or- 
ganisation of  these  classes,  the  methods  of 
operation  and  to  indicate  the  results  which 
they  have  accomplished  or  may  accomplish. 
The  purpose  of  the  nutrition  class  is  to  help 
by  intensive  effort,  largely  educational,  the 
group  of  children  who  by  observations  upon 
weight  and  growth  have  been  found  to  be  so 
far  below  the  normal  average  standard  that 
they  are  in  need  of  special  attention.  In  New 
York  and  in  other  cities  such  classes  have 
multiplied  rapidly,  especially  during  the  last 
two  years.  The  movement  is  the  outcome 
of  the  interest  in  the  nutrition  of  children 
which  has  been  awakened  largely  by  observa- 
tions upon  weight  made  in  general  school  sur- 
veys. It  is  certainly  an  important  health 
movement  and  if  rightly  organised  and  ad- 
ministered it  may  do  for  older  children  what 
the  milk  station  and  the  consultation  have 
done  for  infants. 

Classes  have  been  organised  in  connection 
with  schools,  settlements,  hospitals,  out-pa- 
tient clinics,  church  houses  and  in  many  other 


tlon 


254  FOOD,   HEALTH   AND   GROWTH 

places.  They  have  been  conducted  by  phy- 
sicians, dietitians,  trained  nurses,  social 
workers,  teachers  and  others,  some  of  them 
well  quaUfied,  and  some  with  no  qualifications 
at  all  except  a  general  desire  to  assist  in  solv- 
ing a  difficult  problem. 
Without  some  medical  assistance  a  good 
organisa-  uutrition  class  is  impossible.  Before  chil- 
Administra-  drcu  are  admitted  to  such  a  class  they  should 
receive  a  thorough  medical  examination  to 
determine  whether  they  are  suffering  from 
any  serious  disease,  especially  tuberculosis, 
to  which  failure  to  make  normal  progress  is 
due;  also  whether  there  are  defects  which 
hamper  growth,  like  bad  teeth,  tonsils,  ade- 
noids, etc.  For  there  is  little  hope  of  ma- 
terial improvement  if  there  are  faulty  organic 
conditions  which  are  unrelieved.  The  assist- 
ance of  the  physician  is  necessary  not  only 
for  the  recognition  of  these  conditions  but 
their  correction. 

The  next  step  is  a  careful  investigation 
into  the  child's  diet  and  his  habits;  much 
can  be  learned  from  the  child  himself;  but  a 
knowledge  of  home  conditions  is  indispens- 
able. So  that  there  is  necessary  a  three- 
fold history,  medical,  personal  and  socio- 
logical. Unless  all  these  matters  are  thor- 
oughly considered  at  the  outset  and  definite 


NUTRITION   CLASSES  255 

and  accurate  information  obtained  regarding 
them,  little  that  is  permanent  will  be  accom- 
plished. For  very  often  the  causal  factor 
of  greatest  importance  will  otherwise  be  over- 
looked. It  may  be  largely  poverty  that  is 
the  chief  cause — the  child  does  not  get  enough 
food  or  the  right  kind  of  food  for  the  simple 
reason  that  there  is  not  money  in  the  house 
to  buy  it.  Cooperation  with  relief  organisa- 
tions may  therefore  be  necessary  as  the  first 
step.  In  a  much  larger  number  of  cases  the 
great  causes,  ignorance  and  indifference, 
must  be  overcome. 

One  must  seek  to  awaken  in  the  child  and 
also  in  the  mother  a  desire  for  improvement. 
Much  the  same  methods  of  arousing  interest 
may  be  used  as  those  already  mentioned  in 
discussing  general  health  teaching  in  the 
schools,  viz.,  regular  weekly  weighings  and 
the  stimulus  which  comes  from  the  emulation 
of  being  one  of  a  group.  Close  individual 
attention  is  necessary  in  the  beginning  until 
each  child  is  well  understood. 

One  of  the  great  difficulties  to  overcome 
in  nutrition  classes  is  to  secure  regular  at- 
tendance for  a  period  long  enough  to  get  re-  chlidrea" 
suits.    On  this  account  the  school  seems  to  be  ducted"^' 
the  most  desirable  place   to   conduct   them.  ^'^°°^^ 
Here  in  ideal  conditions  the  cooperation  of 


256  FOOD,    HEALTH  AND   GROWTH 

the  school  physician,  the  school  nurse  and  the 
instructor  in  domestic  science  may  be  of  great 
assistance.  They  should  all  be  members  of 
the  staff  of  such  an  organised  class  as  we 
have  in  mind.  School  work  need  not  be  inter- 
rupted; although  in  most  cases  it  must  be 
modified  to  allow  time  for  extra  rest  periods 
which  most  of  these  children  require.  Open- 
air  classes  in  school  are  of  great  assist- 
ance. 

The  common  practice  of  many  physicians 
of  advising  removal  from  school  for  every 
child  whose  general  condition  is  much  below 
par,  is  by  no  means  the  best  thing  for  most 
of  these  children.  Control  of  energies  and 
regularity  of  habits  are  often  better  secured 
in  the  school  than  in  the  home. 

What  is  absolutely  necessary  is  a  proper 
adjustment  of  study,  exercise  and  rest.  In 
the  school  all  these  can  be  organised  and  reg- 
ularly carried  out.  In  the  home  it  is  often  a 
diflBcult  matter.  To  be  sure,  the  child  is  in 
school  or  under  its  control  only  five  or  six 
hours  out  of  the  twenty-four  and  what  goes 
on  during  the  other  eighteen  hours  is  also 
very  important. 

The  plan  suggested  by  Dr.  Emerson  of  hav- 
ing the  child  keep  for  several  successive  days 
of  ever}'  month  a  record  of  exactly  what  he 


NUTRITION   CLASSES  257 

does  during  each  hour  when  not  in  school,  is 
most  helpful.  Only  in  this  way  can  one  be 
sure  that  directions  given  are  actually  being 
carried  out.  The  offering  of  small  prizes  for 
those  making  most  rapid  progress  is  often 
used  as  an  additional  stimulus. 

When  a  child  has  reached  normal  weight 
for  height  and  his  faulty  habits  and  physical 
defects  have  been  corrected,  he  may  ''gradu- 
ate" from  the  class.  Graduation  is  accom- 
panied by  some  ceremony  and  the  graduate 
is  given  a  certificate  signed  by  the  person  in 
charge  of  the  class  and  sometimes  stamped 
with  an  impressive  red  seal. 

A  comparison  is  sometimes  made  between 
the  results  in  very  marked  cases  of  malnutri- 
tion by  attendance  upon  such  a  nutrition  class 
as  we  have  described,  and  those  obtained  by 
sending  children  for  a  few  weeks  or  even 
longer  period  to  country  homes.  With  the 
latter  much  more  rapid  improvement  usu- 
ally occurs.  A  child  in  two  months  may 
gain  ten  or  fifteen  pounds.  But  this  im- 
provement in  the  great  majority  of  cases 
is  lost  almost  as  rapidly  when  the  child 
returns  to  his  home,  to  his  former  diet  and  his 
old  habits.  Something  more  must  be  done 
for  these  children  than  to  make  them  gain 
weight.    Unless  the  acquisition  of  the  extra 


Sesolts 


EssentliOs 
foi  Success 


258  POOD,   HEALTH  AND   GROWTH 

pounds  has  been  accompanied  by  some  edu- 
cation in  health  the  results  are  very  transient. 
The  educational  process  is  slow;  it  takes  time, 
great  patience  and  much  ingenuity  to  get 
and  to  hold  the  interest  of  the  children,  but 
nothing  else  produces  lasting  results. 

Nutrition  classes,  such  as  we  have  been 
considering,  need  no  elaborate  equipment; 
but  they  do  require  for  success  a  well  trained, 
enthusiastic,  resourceful  personnel.  They 
should  be  conducted  by  those  who  understand 
children  and  have  a  genius  for  influencing 
them;  who  have  also  the  basic  knowledge 
of  the  foods,  diet  and  hygiene  which  are 
necessary  for  children.  The  cooperation  of 
the  home  must  be  secured  and  careful  records 
of  progress  must  be  kept.  A  class  should 
always  have  the  supervision  and  assistance 
of  a  competent  physician. 

All  this  means  that  not  a  great  deal  of  this 
can  be  done  by  volunteer  workers ;  by  far  the 
greater  part  must  be  done  by  a  paid  staff. 
For  intensive  work  classes  cannot  be  large; 
and  for  permanent  results  attendance  must 
be  continued  for  a  long  period,  sometimes  one 
or  two  years.  Good  nutrition  classes  are 
therefore  necessarily  expensive  and  it  is  im- 
possible for  most  communities  to  cover  the 


NUTRITION'   CLASSES  259 

field  with  anything  approaching  thorough- 
ness. 

Such  classes  for  those  suffering  from  mal- 
nutrition are  to  be  regarded  as  curative  or 
corrective  measures.     Since  it  is  more  im- 
portant and  easier  to  keep  well  than  to  get 
well,  the  greater  emphasis  should  be  placed  Prevention 
upon  preventive  measures.    If  proper  health  ponant  than 
teaching  has  been  done  through  the  schools  Measure 
the  necessity  for  nutrition  classes  will  be 
greatly  diminished. 

As  this  work  of  health  education  in  the 
schools  develops  it  becomes  more  and  more 
clear  that  children  can  be  interested  and 
taught  to  practise  proper  health  habits 
through  class-room  teaching  which  can  be 
correlated  w^th  the  regular  studies  and  with- 
out taking  time  from  them.  The  one  thing 
essential  is  a  teacher  with  the  health  point 
of  view.  What  some  such  teachers,  even 
without  special  training,  have  accomplished 
shows  what  is  possible. 

One  cannot  believe  that  ideas  of  health  and 
the  way  to  gain  it  can  be  put  into  the  child's 
mind  during  his  school  years  by  such  meth- 
ods as  we  have  been  considering,  without 
their  making  a  permanent  impression. 

If  what  we  are  striving  for  is  a  better  gen- 


260 


FOOD,    HEALTH   AND   GROWTH 


How  Better 
Trained 
Parents 
are  to  be 
Secured 


eration  of  children  we  must  begin  by  develop- 
ing a  better  generation  of  parents.  The  glar- 
ing defects  at  present  are  in  the  home.  The 
boys  and  girls  now  in  school  will  be  the  par- 
ents of  the  next  generation;  we  should  see 
to  it  that  they  have  a  better  preparation  for 
their  responsibilities  than  their  parents  had. 
What  is  there  which  prevents  it? 

The  greatest  obstacle  in  the  way  of  improv- 
ing the  health  of  children  is  not  poverty ;  it  is 
ignorance  and  indifference.  Dr.  Osier  put  it 
right  when  addressing  a  public  health  meeting 
in  Baltimore.  He  said:  ''Wehave  a  disease  in 
this  city  more  widely  prevalent  than  tubercu- 
losis, more  fatal  than  cancer,  one  that  causes 
many  more  deaths  every  year  than  the  in- 
testinal diseases  of  children."  The  audience, 
the  physicians  as  well  as  others,  wondered 
what  the  Doctor  had  in  mind — when  after 
continuing  in  the  same  strain  for  some  min- 
utes he  announced  that  ''the  disease  is  Balti- 
more apathy."  I  fear  this  disease  is  not  con- 
fined to  Baltimore. 

The  foregoing  discussion  may  be  summed 
up  in  the  following  propositions  which  have 
been  adopted  as  the  creed  of  the  Child  Health 
Organisation: 


CONCLUSION  261 

Every  health  movement  which  is  to  bring  perma- 
nent results  must  have  an  educational  basis. 

It  makes  no  difference  what  the  particular  phase 
of  the  health  problem  is  that  we  are  seeking  to 
solve — ^whether  it  is  cardiac  disease,  hookworm, 
tuberculosis  or  simply  malnutrition  among  chil- 
dren— it  all  comes  back  to  the  education  of  the 
individual  in  matters  of  personal  hygiene. 

To  change  the  health  ideas  and  the  health  habits 
of  adults  is  difficult  and  the  attempt  very  largely  a 
failure. 

Health  education  of  the  future  must  be  directed 
to  the  children. 

If  all  children  are  to  be  reached  this  education 
must  be  given  in  the  schools. 

In  the  past  most  of  the  health  instruction  of 
children  has  succeeded  only  in  making  health  re- 
pulsive. 

The  aim  of  the  Child  Health  Organisation  is  to 
make  the  teaching  of  health  interesting  and  its 
practice  attractive. 

To  initiate  such  a  program  as  we  have  out- 
lined must  be  the  work  of  the  physician;  to 
carry  it  out  is  the  task  of  the  school  authori- 
ties; it  can  succeed  only  when  backed  by  an 
intelligent  public  opinion. 


APPENDIX 

THE    CALORIC    VALUE    OF    COMMON"   ARTICLES   OP    FOOD 

Based  chiefly  on  the  original  tables  of  Atwater  and  Bryant  and 

upon  the  calculations  of  Locke;  partly  calculated  from 

original  observations  made  in  the  laboratory  of 

the  Babies'  Hospital. 


Quantity 


Weight 
grams 


Fat 


Carbo- 
hydrate 


Protein 


Meats 
Beef,   roast,   very   lean .... 
Beef,   round,   fat  removed. 
Beefsteak,     tenderloin  .... 

Lamb,  roast 

Lamb  chop,  tenderloin  only 

Chicken,   roast 

Turkey,  roast 

Beef    juice 

Gravy,    thick 

Bacon,     beechnut,     cooked 
dry  (raw  slice,  13  grams) 

Fith 

Blueflsh   

Cod    

Trout,  brook 

Shellfish 

Clams,  long   

Oysters,  medium  size 

Soups 

Consomme,   canned 

Pea,  cream  soup 

Other    cream    soups    (aver- 
age of  five) 

Vegetable  soup 

Tomato   soup 

Dairy  Products  and  Eggs 
Milk,  whole,  3.5%  fat.  .  . 
Skimmed    milk,    fat-free.  . 

Buttermilk,    fat-free 

Cream,  light,  20%  fat.  .  . 
Cream,  heavy,  40%  fat... 
Condensed  milk,  sweetened 

Butt«r   

Egg,   whole 

(Wt.    with    shell,    SB 
grams. ) 

Egg,  yolk 

Egg,  white 

Vi'getahles 
Baked    beans,    home-made. 

Lima  beans    whole 

String  beans 

Beets   

Cabbage    

Carrots    

Cauliflower   


loss.* 
1  oz. 
1  oz. 
1  oz. 
1  oz. 
1  oz. 
1  oz. 
1  at. 
1  oz. 

1  slice 


1  oz. 
1  oz. 
1  oz. 


4  oz. 
4  oz, 

4  oz. 
4  oz. 
4  oz. 


1  oz. 
1  oz. 
1  oz. 
1  oz. 
1  oz. 
1  oz. 

1  level  tsp. 
1 


1  oz.' 
1  oz. 
1  oz. 
1  w.. 
1  oz. 
1  oz. 
1  oz. 


20 
20 
20 
20 
20 
20 
20 
30 
30 

3.5 


20 
20 
20 


150 


120 
125 

125 
125 
125 


31 
32 
32 
30 
30 
36 
5 
52 


18 
34 


33 

20 
30 
35 
30 
33 
20 


3.0 
14.3 
37.8 
23.7 
23.7 

8.1 
34.0 

6.2 
44.0 

20.0 


8.6 
0.6 
4.4 


14.0 
9.5 


78.6 


83.1 

2.0 


0 
55.9 
111.5 
28.2 
39.7 
55.0 


54.0 
1.0 


26.4 
1.3 
3.0 
0.3 
0.8 
0.5 
0.8 


1.7 


12.0 


1.4 
1.2 


12.2 
12.9 


2.0 
57.6 

29.7 
23.0 
27.7 


5.9 
5.8 
5.0 
2.9 
2.5 
81.5 


29.8 
24.2 
3.0 
10.5 
7.2 
4.7 
3.8 


19.0 
22.7 
19.2 
16.3 
16.3 
26.2 
23.0 
1.8 
6.0 

5.0 


21.4 
18.0 
17.4 


52.8 
21.6 


12.0 
25.8 

13.2 
18.0 
12.4 


4.3 
4.2 
4.0 
3.2 
2.0 

13.3 
0.3 

30.0 


12.0 
18.0 


1.0 
3.2 
2.0 
0.8 
1.4 


*  Cut  in  small   pieces  and  measured  by  volume  ;    1  oz.   approximately   1  round  table- 
spoonful. 

•*  1  oz.   by  volume   approximately   1   round  tablespoonful. 

265 


266 


APPENDIX 


Quantity 


Welgrht 


Fat 


Carbo- 
hydrate 


Protein 


Tumipa 

Spinach  

Com  (cut  off  ear) 

Onions 

Peas   

Asparagus    tips,    mashed . . 

Potato,  white 

Potato,  sweet 

Potato,  baked,  medium  size 

Celery,  one  stalls 

Tomato,  medium  size 

Lettuce   


Bread 
White,  baker's,  slice  3X4 

X^  in 

Whole  wheat,  slice  8X4X 

%  in 

Rolls,    French,    4X2X1% 

in 

Com    bread,    piece,    3%X 

4X%    in 

Zwieback,   small   piece. . . . 

Crackers 

Graham,  3X3  in 

Saltines,  2  in.  square .... 
Uneeda  biscuit,  3  in.  square* 
Wheatsworth,  2X3  in.   . 


1  oz.« 
1  oz. 
1  oz. 
1  oz. 
1  oz. 
1  oz. 
1  oz. 
1  oz. 

1 

4  in.  long 

1 

lleaf 


Cereals 
Farina    and    Cream    of 

Wheat   

Hominy,  boiled    

Commeal    

Oatmeal    

Cornflakes 

Rice,  boiled   

Macaroni,  boiled    

Shredded  wheat  biscuit 

One   rounded   tablespoonful   of   cereal 
One  heaping   tablespoonful   of   cereal 

Fruits,  Fresh 
Apple,     medium,     3%     in. 

diameter   

Grapefruit,     medium,     4^^ 

in.  diameter 

(3%   oz.  juice) 
Orange,   large,   3*^    in.   di- 
ameter      

(5%   oz.  juice) 
Peach,  large,  2\^  in.  diam. 
Pear,  medium,  2%  in.  diam. 


1  oz. 
1  oz. 
1  ox. 
1  oz. 
loz. 
1  oz. 
1  oz. 

1 


% 


30 
30 
30 
30 
80 
30 
30 
30 
80 
8 
100 
10 


80 

42 

40 

40 
7.5 


8.0 
3.0 
6.0 
6.0 


34 
34 
34 
34 
3 
83 
33 
29 


0.5 
1.7 
8.3 
0.6 
0.9 
0.5 
0.3 
1.8 
0.5 
0.1 
1.8 
0.8 


3.6 

8.5 

9.1 

17.0 
7.2 


7.0 
3.4 
5.0 
5.3 


0.9 

0.2 
0.3 
3.2 
0.4 
0.3 
4.U 
3.8 


9.9 

5.8 
28.4 

6.8 
18.6 

4.2 
28.2 
83.7 
70.0 

1.4 
16.4 

1.2 


65.2 

85.6 

89.1 

74.1 
23.6 


24.4 

8.4 

17.7 

18.2 


14.1 
13.4 
12.3 
13.5 
9.4 
30.3 
21.4 
92.7 


1  ounce  by  volume 
1  ^  ounces  by  volume 


200 
250 

300 

128 
150 


5.5 
1.1 

2.4 

1.0 
5.8 


55.2 


87.3 


40.4 
81.0 


1.6 
4.5 
3.3 
1.6 
8.5 
2.3 
8.5 
2.5 
8.5 
0.6 
4.8 
0.6 


11.2 

16.7 

13.6 

12.6 
3.2 


3.6 
1.2 
2.3 
2.5 


2.0 
1.4 
1.4 
3.3 
1.2 
3.4 
4.1 
12.5 


2.2 
2.7 

6.3 

2.6 
3.2 


1   oz.   by   \olume  =.  1   round   tablespoonful. 


APPENDIX 


267 


Quantity 


Weight 

grams 


Strawberries,    medium, 

1  in.  diameter   

(I14  oz-  mashed) 

Banana,  average,  7  in. 
long  (100  g^ams  peeled) 

Orange  juice    

Fruits,  Dried 

Apricots,  large 

Dates,  large 

Figs,  large   

Prunes,  large   

Raisins,  large 

Fruits,  Cooked 

Apple  sauce   

Prune   pulp    

Marmalade,  orange   

Jelly,    currant    

Apple,   baked,  large    

Peaches,  canned,  larg^e,  2% 

in 

Peaches,        canned      (juice 
24%  sug:ar)    

Cakes,  Pastries,  Puddings 
Cookie,  3  in.  diameter... 
Gingerbread,  1X2X3  in.  . 
Sponge    cake,    2X3%X% 

in.    

Lady  finger,  4  in.  long  . . . 

Apple  pie,  y^  pie 

Custard  pie,  1^  pie 

Bread   pudding    

Rice  pudding 

Baked  custard  (8  oz.  milk, 

1  egg,  1  oz.  sugar) .... 
Junket    (8   oz   milk,    1   oz. 

sugar)    

Apple  tapioca 

Ciiocolate  cornstarch 

Ice  cream  *    

Orange  ice   

Tapioca  pudding   

Sujar,  etc. 

Sugar,  gniiiulatcd 

Domino,  half  size    

Domino,  cube 

Honey,    20   c.  c 

Maple  sjrup,  20  c. c 

Karo  corn  syrup,.  20  c.  c.  . 
Ice  cream  soda    


1 
loz. 


1  oz. 
1  oz. 
1  oz. 

1  oz. 
1 

2  halves 
1  oz. 


1 

1  piece 

1  piece 
1 

1  piece 
1  piece 
1  oz. 
1  oz. 

1  oz. 

1  oz. 
1  oz. 
1  oz. 
1  oz. 
loz. 
1  oz. 


1  level  tsp. 

1 

1 

1  tbsp. 

1  tbsp. 

1  tbsp. 

1 


160 
30 


40 

42 

100 

100 

12 


35 
85 

35 

35 

120 

120 

33 


9.5 
60.0 

23.0 

20.0 

126.0 

133.0 


6 

6 

7 

30 

30 

30 


Fat 


6.0 
0.6 


3.7 
9.7 
2.6 


3.5 
1.7 

h'.i 

'  5.4 
1.1 


8.1 
50.3 

22.9 
9.2 
114.9 
77.8 
13.2 
15.7 

17.0 

9.7 

0.6 

24.4 

28.0 

0..^) 

18.2 


Carbo- 
hydrate 


15.2 


92.8 
14.4 


102.5 
120.0 
296.3 
254.6 
35.2 


35.8 

38.2 

103.9 

111.5 

120.1 

46.6 

33.0 


31.0 
156.4 

62.2 
57.8 
221.1 
142.2 
47.2 
35.4 

13.5 

13.8 
3.').1 
38.0 
22.0 
91.8 
29.2 


25 

25 

29 
100 

88 

9,') 
161.9 


Protein 


2.0 


5.2 
LP 


7.8 
3.3 
17.1 
7.4 
1.3 


0.5 
1.8 
0.8 
1.5 
2.5 

3.3 


2.9 
14.3 

6.0 

7.0 

16.0 

23.0 

7.6 


4.5 
0.3 
6.6 
6.5 
1.7 
7.6 


1.0 
'21.4 


*  Made  witli  egg. . 


268 


APPENDIX 


CALORIM 

Quantity 

Weight 
grams 

Fat 

Carbo- 
hydrate 

Protein 

Total 

Chocolate  sauce   

loe. 

1  piece 
1  piece 

1 

1 

loe. 

lot. 
1  tsp. 
lUp. 
10 

1 

10 

28 

7 
27 

25 
80 

2.5 

9 
20 

4 

36.0 

29.0 
20.2 

0.3 

0 

235 
43 

6.8 
89.0 
64 
26.3 

112.0 

26.0 
46.6 

26.7 

107.0 

0 
12.8 

3.9 

6.3 
15.0 

2.4 

4.0 

S.O 
8.3 

0 

0 

0 

6.2 

2.3 
10.7 
16.0 

8.8 

162 

Hilk    chocolate.    1X2X% 
in 

58 

Fudge,   1X1X\   in 

Peppermints,    plain,    1    in. 

70 
27 

Lollypop,    1%X%    in.    di- 

107 

Mucellaneotu 
Olive   oil    

235 

61 

Cocoa    

13 

56 

85 

Walnuts    

81 

INDEX 


Accessory   food   factors    (see   Vi- 

tamines). 
Activity,  caloric  requirements  for, 

55. 
increased     caloric     requirements 

during,  67, 
Adolescence,      food      requirements 

during,  66. 
food   needs   greater   during,   76. 
American  children,  size  of,  20. 
Amino-acids,  essential  for  growth, 

89. 
Antiscorbutic  foods,   177,  183. 
Antiscorbutic    vitamine     (see    Vi- 

tamine   C). 
Ayers,  on  school  retardation,  23. 

Balanced  ration,  importance  of, 
147. 

Benedict  and  Talbot,  basal  re- 
quirements,  50. 

Beriberi,    152,    172. 

Blanton,  on  German  children  with 
malnutrition,   30. 

Bloch,  eye  disease  in  infants  from 
deficiency  of  fat,  163. 

Bones,  salts  needed  for,  139. 

Bryant,  school  survey,  25. 

Cabbage,  207. 

Calcium,    milk    important    source, 

138. 
California   children,    size,   21. 
Caloric  requirements,  basal,  50. 

for  growth,   54. 

for  activity,  55. 

estimate  of,  60. 

complete  daily  schedule,  73. 


Calorie,  definition,  47. 
Calories,  for  basal  metabolism,  50. 
growth  allowance,  54. 
activity  allowance,  55. 
excreta  allowance,  60. 
total  requirements,  60. 
per   kilo,   65. 

complete  schedules  per  kilo,  67. 
complete     schedules,     daily     re- 
quirements,   73. 
taken  by   100   healthy  children, 

78. 
table     giving     suggested     total 

daily,   84. 
distribution  of  in  diet,  139. 
Camerer,  total  calories,  61,  65. 
protein  intake,  100. 
fat  intake,  117. 
distribution    of    calories,    146. 
Candy,  consumption  of,  124. 
Carbohydrate,  functions  of,   120. 
requirement,    120. 
intake  of  infants,  123. 
of  older  children,  124. 
of  adults,  126. 
tendency  to  overfeed  with,  124. 
proportion  taken  as  sugar,   128. 
and   dental   caries,    131. 
amount   recommended,   132. 
Carbohydrates,  effect  of  excess  of, 
37,  129,  131. 
economical,  121. 
Chick  and  Ilume,  observations  on 
vitamine   C,    182. 
amount  of  vitamine  required  for 
protection,    197. 
Child    Health    Organisation,    creed 
of,  260. 


269 


270 


INDEX 


Club  motive,  use  of  in  health  in- 
struction, 233. 

Condensed  milk,  effects  of,  130. 

Cow 's  milk,  low  in  iron,  137. 

Jzerny  and  Keller,  Mehlndhr- 
schaden,  165. 

Deficiency  diseases,  44. 

Dental    caries    and    carbohydrates, 

131. 
Detroit,  school  survey,  27. 
Draft,  results  of,  7. 

Education,  of  parents,  10,  260. 
importance  of,  in  nutrition  prob- 
lem, 209. 
disease   prevented   by,   220. 
of  adults,  difficult,  223. 
Eijkman,     early     observations    on 

beriberi,   173. 
Energy,  definition,  87. 
Excreta,   calories  lost   in,  58. 

Fat,  requirement,    107. 
function  of,  108. 
effect    of,    on    mineral    metabo- 
lism, 111. 
starvation   and  susceptibility  to 

infections,    112. 
intake  of  nursing  infant,  115. 
of  artificially-fed  infants,  116. 
of  older  children,  116. 
of  adolescent  boys,  118. 
symptoms  due  to  excess  of,  118. 
amount    recommended,    120. 
Fat-soluble    vitamine     (see    Vita- 
mine  A). 
Food,  influence  of,  on  growth,  17. 
of    Japanese    children,    18. 
requirements,    47. 
valued  by  vitamine  content,  191. 
Poods,  injure<l  by  preservation  and 
storage,   192. 
infant,   deficiency    in    vitamines, 
199. 
Funk,    observations    on    beriberi, 
152. 


Gephart,  observations  at  St.  Paul  'a 

School,   62,   100,   117,   125. 
Gillett,    caloric    intaJce,    60, 

protein  intake,  99. 
Gillett    and    Sherman,    calorie    in- 
take, 66. 
Government,   expenditure   for   De- 
partment of  Animal  Industry, 
14. 
appropriation      for      Children 's 
Bureau,  15. 
Growth,      determined      by      food, 
18. 
of  Japanese  children,  19. 
effects  of  prolonged  underfeed- 
ing on,  42. 
caloric  requirements  for,  52. 
estimated    calories    needed    for, 

54. 
amino-acids    necessary    for,    89. 
protein   allowance    for,   92. 
Growth  rate,  52. 

Habits,  bad,  a  cause  of  malnutri- 
tion, 211. 
formation,    essential    to    health, 
231. 
Hart,    Steeubock    and    Ellis,    vita- 
mine   content   of   cow's   milk, 
187. 
Health,  competition  in,  242. 
municipal     appropriations     for, 
15. 
Health  education,   preventing  dis- 
ease by,  220. 
in  home,  224. 
in   school,   225. 
by  older  methods,  226. 
successful       and       unsuccessfuj 

methods   in,   230. 
play   motive   in,   232. 
club  motive  in,  233. 
of    older   children,    244. 
of    teacher,    248. 
correlated  with  other  school  sub. 
jcets,   246,   250. 
Health  habits,  231. 


INDEX 


271 


Health  literature  for  children,  238. 

plays,   236. 

posters,    237. 

rhymes,   237. 
Hess,    on    antiscorbutic    vitamine, 

201. 
Hill,     observaticna     in     Germany, 

57. 
Hopkins,  early  observations  on  vi- 

tamines,    152. 
Hoist,  scurvy  in  animals,  158. 

Infancy,    period    of    susceptibility 
to  vitamine  deficiency,  198. 

Infection,  resistance  to,  dependent 
upon  nutrition,  33. 
susceptibility    of    delicate    chil- 
dren to,  35. 

Iron,  deficiency  of,  in  cow's  milk, 
137. 

Japanese  children,  food  of,  18. 

growth    of,    19. 
Jews,     Russian,     growth     of,     in 
U.  S.,  20. 

Kerato-malacia,  163. 

Lard,  vitamine  A  in,  189. 
Lusk,  estimate  for  caloric  require- 
ments, 56,  67. 

Malnutrition,  extent  of,  8,  215. 

nervous   symptoms   in,   31,   214. 

causes  of,  209. 

evidences  of,  214. 

prevention  of,  215. 
McCollum  and  Davis,  on  vitamines, 

155. 
Medical  school  examinations,  218. 
MehhidhrscJiaden,    165. 
Metabolism,  definition,  47. 

basal,  50. 
Milk,  an  important  source  of  cal- 
cium,  138. 

effect   of   heating,   on   vitamine 
C,  178. 


Milk,       importance      of       during 
growth,  206. 
amount    required,    206. 
Mineral   salts,   functions  of,   135. 
Mortality,     infant,     reduction    of, 

5,    219. 
Miiller,    on    calories    lost    in    ex- 
creta,   59. 
on  protein  intake,  100. 
on  fat  intake.  117. 

Nervous  symptoms,  and  malnutri- 
tion, 31,  214. 
Noel   and   Paton,   observations   an 

Vienna  children,   43. 
Nutrition,   factors   influencing,   17. 
importance   of    in   treatment   of 

disease,   36. 
in   chronic   disease,   38. 
in  organic  disease,  39. 
in   chronic   nervous   disease,   41. 
practical    measures   for   improv- 
ing, 208. 
weight-height  relationship,  index 
to,  212. 
Nutrition  classes,   253. 

Orange   juice,    amount   needed   to 

protect  against  scurvy,  182. 
Osborne  and  Mendel,  effect  of  dif- 
ferent proteins  on  growth  of 
rats,  93. 
of    salts,   on   growth   of    rats, 

93. 
of  vitamine   B,   on   growth  of 
rats,  170. 
low-fat    diet,    109. 
early  observations  on  vitamines, 
154. 
Oxidation,  effect  of,  on  vitamines, 
185. 

Packer  and  Moehlman,  school  sur- 
vey by,  27. 

Parents,   education   of,    10,   260. 

Paton  and  Watson,  obser\'ation3 
on  rickets,  168. 


272 


INDEX 


Physical    education    and    training 

not   health    teaching,    227. 
Play  motive,  use  of  in  health   in- 
struction, 232. 
Porter,  observations  on  growth  and 

school    progress,    24. 
Pre-school  child,  neglect  of,  6. 

ways  of   reaching,   216. 
Preventive  medicine,  opposition  to, 

12. 
Protein  intake  of  healthy  children, 

101. 
Proteins,    composition    of,    88. 
adult  requirement,  90. 
animal,    preferable    for    growth, 

90,  92. 
animal  vs.  vegetable,  91,  106. 
growth  allowance,  92. 
effect  of  different,  on  growth  of 

rats,   93. 
in  woman's  milk,  94. 
in  cow 's  milk,  96. 
in    condensed    milk,   97, 
amount    needed    by    infants   tak- 
ing cow's  milk,  98. 
amount   for  older  children,  99. 
amount    per    kilo,    103. 
vegetable,      of      lower      grade, 
106. 

Rickets,  causes  of,  167. 
Ross,  on  kerato-malacia,   164. 

School  retardation,  22. 

Scur\T,       a       deficiency       disease, 

157. 
time  required  to  produce,   180. 
Smith,    Theobald,    observations  on 

scurvy  in  animals,  158. 
St.    Paul 's  School,   calories   taken 

by  boys  in,  62. 
Stunted  children,  213. 

Tigerstedt,  on  total  calories,  62. 

Underfeeding,  effects  of,  3. 
arrest  of   growth   in,   42. 


Vegetables,    importance    of,    170, 

176,  204. 
Vitamine  A,  157. 

sources  of,   159. 

symptoms   due  to   deficiency  of, 
161,   163. 
Vitamine  B,   157, 

sources  of,  169. 

symptoms   due  to   deficiency   of, 
171. 
Vitamine  C,  159. 

not  needed  by  certain  animals, 
175. 

sources  of,  176. 

injured  by  heat,   176,   179. 

small   amount    of    in   milk,    178. 

amount    needed    for    protection 
against  scurvy,   181. 
Vitamines,  149. 

early    observations    of    Hopkins 
on,  152. 

effect   of  oxidation  on,   185. 

solubility   of,   186. 

effect  of  food  upon  amount  of, 
in   cow's   milk,    187. 
in   woman 's   milk,    187. 

in  diet  of  nursing  mother,   187. 

deficiency       of,       when       likely, 
195. 

requirements,    conditions    affect- 
ing,  197. 

deficiency   of,   in   infancy,   198. 

specific   action   of,    199. 

sjTiiptoms    due    to    relative    de- 
ficiency of,  200. 

commercial       exploitation        of, 
203. 

use   not   indicated   when  no   de- 
ficiency, 203. 
Von    Groer,    infants    on    fat-free 
diet,  110. 

War  edema,   165. 

Washington,  survey  of  school  chil- 
dren in,  26. 

Water-soluble  vitamine  (see  Vita- 
mine B), 


INDEX 


273 


Weighing,  how  used  in  health  edu- 
cation, 240. 

Weight-height  relationship,  an  in- 
dex to  nutrition,  212. 

Weight  records,  value  and  purpose 
of,  238. 

White  wheat  flour,  advantages  and 
disadvantages  of,  192. 


Whole  wheat  flour,  advantage!  and 
disadvantages  of,   193. 

Xerophthalmia,  162. 

Yeast,  vitamines  in,   155. 
in  malnutrition,  202. 


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